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Centner FS, Wenz H, Oster ME, Dally FJ, Sauter-Servaes J, Pelzer T, Schoettler JJ, Hahn B, Abdulazim A, Hackenberg KAM, Groden C, Krebs J, Thiel M, Etminan N, Maros ME. Sepsis and delayed cerebral ischemia are associated and have a cumulative effect on poor functional outcome in aneurysmal subarachnoid hemorrhage. Front Neurol 2024; 15:1393989. [PMID: 38882701 PMCID: PMC11179438 DOI: 10.3389/fneur.2024.1393989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 05/22/2024] [Indexed: 06/18/2024] Open
Abstract
Objective Although sepsis and delayed cerebral ischemia (DCI) are severe complications in patients with aneurysmal subarachnoid hemorrhage (aSAH) and share pathophysiological features, their interrelation and additive effect on functional outcome is uncertain. We investigated the association between sepsis and DCI and their cumulative effect on functional outcome in patients with aSAH using current sepsis-3 definition. Methods Patients admitted to our hospital between 11/2014 and 11/2018 for aSAH were retrospectively analyzed. The main explanatory variable was sepsis, diagnosed using sepsis-3 criteria. Endpoints were DCI and functional outcome at hospital discharge (modified Rankin Scale (mRS) 0-3 vs. 4-6). Propensity score matching (PSM) and multivariable logistic regressions were performed. Results Of 238 patients with aSAH, 55 (23.1%) developed sepsis and 74 (31.1%) DCI. After PSM, aSAH patients with sepsis displayed significantly worse functional outcome (p < 0.01) and longer ICU stay (p = 0.046). Sepsis was independently associated with DCI (OR = 2.46, 95%CI: 1.28-4.72, p < 0.01). However, after exclusion of patients who developed sepsis before (OR = 1.59, 95%CI: 0.78-3.24, p = 0.21) or after DCI (OR = 0.85, 95%CI: 0.37-1.95, p = 0.70) this statistical association did not remain. Good functional outcome gradually decreased from 56.3% (76/135) in patients with neither sepsis nor DCI, to 43.8% (21/48) in those with no sepsis but DCI, to 34.5% (10/29) with sepsis but no DCI and to 7.7% (2/26) in patients with both sepsis and DCI. Conclusion Our study demonstrates a strong association between sepsis, DCI and functional outcome in patients with aSAH and suggests a complex interplay resulting in a cumulative effect towards poor functional outcome, which warrants further studies.
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Affiliation(s)
- Franz-Simon Centner
- Department of Anesthesiology, Surgical Intensive Care Medicine and Pain Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Holger Wenz
- Department of Neuroradiology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Mariella Eliana Oster
- Department of Anesthesiology, Surgical Intensive Care Medicine and Pain Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Franz-Joseph Dally
- Department of Anesthesiology, Surgical Intensive Care Medicine and Pain Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
- Department of Orthopedics and Trauma Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Johannes Sauter-Servaes
- Department of Anesthesiology, Surgical Intensive Care Medicine and Pain Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Tanja Pelzer
- Department of Anesthesiology, Surgical Intensive Care Medicine and Pain Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
- Department of Neonatology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Jochen J Schoettler
- Department of Anesthesiology, Surgical Intensive Care Medicine and Pain Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Bianka Hahn
- Department of Anesthesiology, Surgical Intensive Care Medicine and Pain Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Amr Abdulazim
- Department of Neurosurgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Katharian A M Hackenberg
- Department of Neurosurgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Christoph Groden
- Department of Neuroradiology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Joerg Krebs
- Department of Anesthesiology, Surgical Intensive Care Medicine and Pain Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Manfred Thiel
- Department of Anesthesiology, Surgical Intensive Care Medicine and Pain Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Nima Etminan
- Department of Neurosurgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Máté E Maros
- Department of Neuroradiology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
- Department of Biomedical Informatics at the Center for Preventive Medicine and Digital Health (CPD), University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
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Zunino G, Battaglini D, Godoy DA. Effects of positive end-expiratory pressure on intracranial pressure, cerebral perfusion pressure, and brain oxygenation in acute brain injury: Friend or foe? A scoping review. JOURNAL OF INTENSIVE MEDICINE 2024; 4:247-260. [PMID: 38681785 PMCID: PMC11043646 DOI: 10.1016/j.jointm.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/27/2023] [Accepted: 08/05/2023] [Indexed: 05/01/2024]
Abstract
Background Patients with acute brain injury (ABI) are a peculiar population because ABI does not only affect the brain but also other organs such as the lungs, as theorized in brain-lung crosstalk models. ABI patients often require mechanical ventilation (MV) to avoid the complications of impaired respiratory function that can follow ABI; MV should be settled with meticulousness owing to its effects on the intracranial compartment, especially regarding positive end-expiratory pressure (PEEP). This scoping review aimed to (1) describe the physiological basis and mechanisms related to the effects of PEEP in ABI; (2) examine how clinical research is conducted on this topic; (3) identify methods for setting PEEP in ABI; and (4) investigate the impact of the application of PEEP in ABI on the outcome. Methods The five-stage paradigm devised by Peters et al. and expanded by Arksey and O'Malley, Levac et al., and the Joanna Briggs Institute was used for methodology. We also adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension criteria. Inclusion criteria: we compiled all scientific data from peer-reviewed journals and studies that discussed the application of PEEP and its impact on intracranial pressure, cerebral perfusion pressure, and brain oxygenation in adult patients with ABI. Exclusion criteria: studies that only examined a pediatric patient group (those under the age of 18), experiments conducted solely on animals; studies without intracranial pressure and/or cerebral perfusion pressure determinations, and studies with incomplete information. Two authors searched and screened for inclusion in papers published up to July 2023 using the PubMed-indexed online database. Data were presented in narrative and tubular form. Results The initial search yielded 330 references on the application of PEEP in ABI, of which 36 met our inclusion criteria. PEEP has recognized beneficial effects on gas exchange, but it produces hemodynamic changes that should be predicted to avoid undesired consequences on cerebral blood flow and intracranial pressure. Moreover, the elastic properties of the lungs influence the transmission of the forces applied by MV over the brain so they should be taken into consideration. Currently, there are no specific tools that can predict the effect of PEEP on the brain, but there is an established need for a comprehensive monitoring approach for these patients, acknowledging the etiology of ABI and the measurable variables to personalize MV. Conclusion PEEP can be safely used in patients with ABI to improve gas exchange keeping in mind its potentially harmful effects, which can be predicted with adequate monitoring supported by bedside non-invasive neuromonitoring tools.
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Affiliation(s)
- Greta Zunino
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Dipartimento di Scienze Diagnostiche e Chirurgiche Integrate, Università degli Studi di Genova, Genova, Italy
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Robba C, Battaglini D, Cinotti R, Asehnoune K, Stevens R, Taccone FS, Badenes R, Pelosi P. Individualized Thresholds of Hypoxemia and Hyperoxemia and their Effect on Outcome in Acute Brain Injured Patients: A Secondary Analysis of the ENIO Study. Neurocrit Care 2024; 40:515-528. [PMID: 37322325 DOI: 10.1007/s12028-023-01761-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 05/16/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND In acute brain injury (ABI), the effects of hypoxemia as a potential cause of secondary brain damage and poor outcome are well documented, whereas the impact of hyperoxemia is unclear. The primary aim of this study was to assess the episodes of hypoxemia and hyperoxemia in patients with ABI during the intensive care unit (ICU) stay and to determine their association with in-hospital mortality. The secondary aim was to identify the optimal thresholds of arterial partial pressure of oxygen (PaO2) predicting in-hospital mortality. METHODS We conducted a secondary analysis of a prospective multicenter observational cohort study. Adult patients with ABI (traumatic brain injury, subarachnoid aneurysmal hemorrhage, intracranial hemorrhage, ischemic stroke) with available data on PaO2 during the ICU stay were included. Hypoxemia was defined as PaO2 < 80 mm Hg, normoxemia was defined as PaO2 between 80 and 120 mm Hg, mild/moderate hyperoxemia was defined as PaO2 between 121 and 299 mm Hg, and severe hyperoxemia was defined as PaO2 levels ≥ 300 mm Hg. RESULTS A total of 1,407 patients were included in this study. The mean age was 52 (±18) years, and 929 (66%) were male. Over the ICU stay, the fractions of patients in the study cohort who had at least one episode of hypoxemia, mild/moderate hyperoxemia, and severe hyperoxemia were 31.3%, 53.0%, and 1.7%, respectively. PaO2 values below 92 mm Hg and above 156 mm Hg were associated with an increased probability of in-hospital mortality. Differences were observed among subgroups of patients with ABI, with consistent effects only seen in patients without traumatic brain injury. CONCLUSIONS In patients with ABI, hypoxemia and mild/moderate hyperoxemia were relatively frequent. Hypoxemia and hyperoxemia during ICU stay may influence in-hospital mortality. However, the small number of oxygen values collected represents a major limitation of the study.
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Affiliation(s)
- Chiara Robba
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical Science and Integrated Diagnostic, University of Genova, Genova, Italy
| | | | - Raphael Cinotti
- Department of Anesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, Nantes, France
- UMR 1246 SPHERE Methods in Patients-Centered Outcomes and Health Research, University of Nantes, University of Tours, INSERM, Nantes, France
| | - Karim Asehnoune
- Department of Anesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, Nantes, France
| | - Robert Stevens
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Rafael Badenes
- Anesthesiology and Surgical-Trauma Intensive Care, University Clinic Hospital, Valencia, Spain
- Department of Surgery, University of Valencia, Valencia, Spain
- INCLIVA Research Medical Institute, Valencia, Spain
| | - Paolo Pelosi
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical Science and Integrated Diagnostic, University of Genova, Genova, Italy
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Thilak S, Brown P, Whitehouse T, Gautam N, Lawrence E, Ahmed Z, Veenith T. Diagnosis and management of subarachnoid haemorrhage. Nat Commun 2024; 15:1850. [PMID: 38424037 PMCID: PMC10904840 DOI: 10.1038/s41467-024-46015-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 02/12/2024] [Indexed: 03/02/2024] Open
Abstract
Aneurysmal subarachnoid haemorrhage (aSAH) presents a challenge to clinicians because of its multisystem effects. Advancements in computed tomography (CT), endovascular treatments, and neurocritical care have contributed to declining mortality rates. The critical care of aSAH prioritises cerebral perfusion, early aneurysm securement, and the prevention of secondary brain injury and systemic complications. Early interventions to mitigate cardiopulmonary complications, dyselectrolytemia and treatment of culprit aneurysm require a multidisciplinary approach. Standardised neurological assessments, transcranial doppler (TCD), and advanced imaging, along with hypertensive and invasive therapies, are vital in reducing delayed cerebral ischemia and poor outcomes. Health care disparities, particularly in the resource allocation for SAH treatment, affect outcomes significantly, with telemedicine and novel technologies proposed to address this health inequalities. This article underscores the necessity for comprehensive multidisciplinary care and the urgent need for large-scale studies to validate standardised treatment protocols for improved SAH outcomes.
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Affiliation(s)
- Suneesh Thilak
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
| | - Poppy Brown
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
| | - Tony Whitehouse
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| | - Nandan Gautam
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
| | - Errin Lawrence
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| | - Zubair Ahmed
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Tonny Veenith
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK.
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, B15 2TT, UK.
- Department of Critical Care Medicine and Anaesthesia, The Royal Wolverhampton NHS Foundation Trust, New Cross Hospital, Wolverhampton, WV10 0QP, UK.
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Dey A, Khandelwal A. Hyperoxia in neurocritical care: Current perspectives. Med J Armed Forces India 2024; 80:10-15. [PMID: 38239601 PMCID: PMC10793228 DOI: 10.1016/j.mjafi.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 11/29/2022] [Indexed: 01/18/2023] Open
Abstract
In recent years, a lot of controversies have emerged regarding conservative versus liberal oxygen therapy in critically ill patients. While neurologically injured patients might have higher oxygen demand due to high cerebral metabolism, recent studies have clearly shown that hyperoxia may not be beneficial in improving the neurological outcome in traumatic brain injury, subarachnoid hemorrhage, and acute ischemic stroke. Rather, hyperoxia might worsen neurological outcome in such conditions by various mechanisms like direct cerebral vasoconstriction or by increased excitotoxicity, which in turn leads to lipid peroxidation and generation of harmful reactive oxygen species. This article brings into insight the current evidence on the effect of hyperoxia on these three acute neurological insults.
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Affiliation(s)
- Ankita Dey
- Assistant Professor (Anaesthesia), All India Institute of Medical Sciences (AIIMS), Bathinda, India
| | - Ankur Khandelwal
- Associate Professor (Anaesthesiology, Critical Care & Pain Medicine), All India Institute of Medical Sciences (AIIMS), Guwahati, Assam, India
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Salvagno M, Taccone FS, Bogossian EG. Tissue hyperoxia is not a risk factor for cerebral vasospasm following subarachnoid hemorrhage. J Neurol Sci 2023; 445:120535. [PMID: 36630804 DOI: 10.1016/j.jns.2022.120535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/22/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022]
Affiliation(s)
- Michele Salvagno
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium.
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
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Svedung Wettervik T, Lewén A, Enblad P. Fine tuning of neurointensive care in aneurysmal subarachnoid hemorrhage: From one-size-fits-all towards individualized care. World Neurosurg X 2023; 18:100160. [PMID: 36818739 PMCID: PMC9932216 DOI: 10.1016/j.wnsx.2023.100160] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 01/25/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a severe type of acute brain injury with high mortality and burden of neurological sequelae. General management aims at early aneurysm occlusion to prevent re-bleeding, cerebrospinal fluid drainage in case of increased intracranial pressure and/or acute hydrocephalus, and cerebral blood flow augmentation in case of delayed ischemic neurological deficits. In addition, the brain is vulnerable to physiological insults in the acute phase and neurointensive care (NIC) is important to optimize the cerebral physiology to avoid secondary brain injury. NIC has led to significantly better neurological recovery following aSAH, but there is still great room for further improvements. First, current aSAH NIC management protocols are to some extent extrapolated from those in traumatic brain injury, notwithstanding important disease-specific differences. Second, the same NIC management protocols are applied to all aSAH patients, despite great patient heterogeneity. Third, the main variables of interest, intracranial pressure and cerebral perfusion pressure, may be too superficial to fully detect and treat several important pathomechanisms. Fourth, there is a lack of understanding not only regarding physiological, but also cellular and molecular pathomechanisms and there is a need to better monitor and treat these processes. This narrative review aims to discuss current state-of-the-art NIC of aSAH, knowledge gaps in the field, and future directions towards a more individualized care in the future.
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Affiliation(s)
- Teodor Svedung Wettervik
- Corresponding author. Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85 Uppsala, Sweden.
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Lu W, Tong Y, Zhang C, Xiang L, Xiang L, Chen C, Guo L, Shan Y, Li X, Zhao Z, Pan X, Zhao Z, Zou J. A novel visual dynamic nomogram to online predict the risk of unfavorable outcome in elderly aSAH patients after endovascular coiling: A retrospective study. Front Neurosci 2023; 16:1037895. [PMID: 36704009 PMCID: PMC9871773 DOI: 10.3389/fnins.2022.1037895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/22/2022] [Indexed: 01/12/2023] Open
Abstract
Background Aneurysmal subarachnoid hemorrhage (aSAH) is a significant cause of morbidity and mortality throughout the world. Dynamic nomogram to predict the prognosis of elderly aSAH patients after endovascular coiling has not been reported. Thus, we aimed to develop a clinically useful dynamic nomogram to predict the risk of 6-month unfavorable outcome in elderly aSAH patients after endovascular coiling. Methods We conducted a retrospective study including 209 elderly patients admitted to the People's Hospital of Hunan Province for aSAH from January 2016 to June 2021. The main outcome measure was 6-month unfavorable outcome (mRS ≥ 3). We used multivariable logistic regression analysis and forwarded stepwise regression to select variables to generate the nomogram. We assessed the discriminative performance using the area under the curve (AUC) of receiver-operating characteristic and the risk prediction model's calibration using the Hosmer-Lemeshow goodness-of-fit test. The decision curve analysis (DCA) and the clinical impact curve (CIC) were used to measure the clinical utility of the nomogram. Results The cohort's median age was 70 (interquartile range: 68-74) years and 133 (36.4%) had unfavorable outcomes. Age, using a ventilator, white blood cell count, and complicated with cerebral infarction were predictors of 6-month unfavorable outcome. The AUC of the nomogram was 0.882 and the Hosmer-Lemeshow goodness-of-fit test showed good calibration of the nomogram (p = 0.3717). Besides, the excellent clinical utility and applicability of the nomogram had been indicated by DCA and CIC. The eventual value of unfavorable outcome risk could be calculated through the dynamic nomogram. Conclusion This study is the first visual dynamic online nomogram that accurately predicts the risk of 6-month unfavorable outcome in elderly aSAH patients after endovascular coiling. Clinicians can effectively improve interventions by taking targeted interventions based on the scores of different items on the nomogram for each variable.
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Affiliation(s)
- Wei Lu
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China,Department of Pharmacy, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - YuLan Tong
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China,Department of Pharmacy, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Cheng Zhang
- Department of Neurology, The First Affiliated Hospital (People’s Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Lan Xiang
- Department of Neurology, The First Affiliated Hospital (People’s Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Liang Xiang
- Department of Neurology, The First Affiliated Hospital (People’s Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Chen Chen
- Department of Pharmacy, Nanjing First Hospital, Nanjing Medical University, Nanjing, China,Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing, China
| | - LeHeng Guo
- Department of Neurology, The First Affiliated Hospital (People’s Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - YaJie Shan
- Department of Neurology, The First Affiliated Hospital (People’s Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - XueMei Li
- Department of Neurology, The First Affiliated Hospital (People’s Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Zheng Zhao
- Department of Pharmacy, Nanjing First Hospital, Nanjing Medical University, Nanjing, China,Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing, China
| | - XiDing Pan
- Department of Pharmacy, Nanjing First Hospital, Nanjing Medical University, Nanjing, China,Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing, China,XiDing Pan,
| | - ZhiHong Zhao
- Department of Neurology, The First Affiliated Hospital (People’s Hospital of Hunan Province), Hunan Normal University, Changsha, China,ZhiHong Zhao,
| | - JianJun Zou
- Department of Pharmacy, Nanjing First Hospital, Nanjing Medical University, Nanjing, China,Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing, China,*Correspondence: JianJun Zou,
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Kılınç Z, Ayyıldız EA, Kaya E, Sahin AS. The Effect of Oxygenation on Mortality in Patients With Head Injury. Cureus 2023; 15:e34385. [PMID: 36874741 PMCID: PMC9976649 DOI: 10.7759/cureus.34385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2023] [Indexed: 02/03/2023] Open
Abstract
Introduction In this study, we planned to investigate the effect of hyperoxygenation on mortality and morbidity in patients with head trauma who were followed and treated in the intensive care unit (ICU). Methods Head trauma cases (n = 119) that were followed in the mixed ICU of a 50-bed tertiary care center in Istanbul between January 2018 and December 2019 were retrospectively analyzed for the negative effects of hyperoxia. Age, gender, height/weight, additional diseases, medications used, ICU indication, Glasgow Coma Scale score recorded during ICU follow-up, Acute Physiology and Chronic Health Evaluation (APACHE) II score, length of hospital/ICU stay, the presence of complications, number of reoperations, length of intubation, and the patient's discharge or death status were evaluated. The patients were divided into three groups according to the highest partial pressure of oxygen (PaO2) value (200 mmHg) in the arterial blood gas (ABG) taken on the first day of admission to the ICU, and ABGs on the day of ICU admission and discharge were compared. Results In comparison, the first arterial oxygen saturation and initial PaO2 mean values were found to be statistically significantly different. There was a statistically significant difference in mortality and reoperation rates between groups. The mortality was higher in groups 2 and 3, and the rate of reoperation was higher in group 1. Conclusion In our study, mortality was found to be high in groups 2 and 3, which we considered hyperoxic. In this study, we tried to draw attention to the negative effects of common and easily administered oxygen therapy on mortality and morbidity in ICU patients.
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Affiliation(s)
- Zehra Kılınç
- Anesthesiology and Reanimation, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, TUR
| | - Elif Aybike Ayyıldız
- Anesthesiology and Reanimation, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, TUR
| | - Ebru Kaya
- Intensive Care Unit, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, TUR
| | - Ayca Sultan Sahin
- Anesthesiology and Reanimation, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, TUR
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10
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Brain Oxygen-Directed Management of Aneurysmal Subarachnoid Hemorrhage. Temporal Patterns of Cerebral Ischemia During Acute Brain Attack, Early Brain Injury, and Territorial Sonographic Vasospasm. World Neurosurg 2022; 166:e215-e236. [PMID: 35803565 DOI: 10.1016/j.wneu.2022.06.149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Neurocritical management of aneurysmal subarachnoid hemorrhage focuses on delayed cerebral ischemia (DCI) after aneurysm repair. METHODS This study conceptualizes the pathophysiology of cerebral ischemia and its management using a brain oxygen-directed protocol (intracranial pressure [ICP] control, eubaric hyperoxia, hemodynamic therapy, arterial vasodilation, and neuroprotection) in patients with subarachnoid hemorrhage, undergoing aneurysm clipping (n = 40). RESULTS The brain oxygen-directed protocol reduced Lbo2 (Pbto2 [partial pressure of brain tissue oxygen] <20 mm Hg) from 67% to 15% during acute brain attack (<24 hours of ictus), by increasing Pbto2 from 11.31 ± 9.34 to 27.85 ± 6.76 (P < 0.0001) and then to 29.09 ± 17.88 within 72 hours. Day-after-bleed, Fio2 change, ICP, hemoglobin, and oxygen saturation were predictors for Pbto2 during early brain injury. Transcranial Doppler ultrasonography velocities (>20 cm/second) increased at day 2. During DCI caused by territorial sonographic vasospasm (TSV), middle cerebral artery mean velocity (Vm) increased from 45.00 ± 15.12 to 80.37 ± 38.33/second by day 4 with concomitant Pbto2 reduction from 29.09 ± 17.88 to 22.66 ± 8.19. Peak TSV (days 7-12) coincided with decline in Pbto2. Nicardipine mitigated Lbo2 during peak TSV, in contrast to nimodipine, with survival benefit (P < 0.01). Intravenous and cisternal nicardipine combination had survival benefit (Cramer Φ = 0.43 and 0.327; G2 = 28.32; P < 0.001). This study identifies 4 zones of Lbo2 during survival benefit (Cramer Φ = 0.43 and 0.3) TSV, uncompensated; global cerebral ischemia, compensated, and normal Pbto2. Admission Glasgow Coma Scale score (not increased ICP) was predictive of low Pbto2 (β = 0.812, R2 = 0.661, F1,30 = 58.41; P < 0.0001) during early brain injury. Coma was the only credible predictor for mortality (odds ratio, 7.33/>4.8∗; χ2 = 7.556; confidence interval, 1.70-31.54; P < 0.01) followed by basilar aneurysm, poor grade, high ICP and Lbo2 during TSV. Global cerebral ischemia occurs immediately after the ictus, persisting in 30% of patients despite the high therapeutic intensity level, superimposed by DCI during TSV. CONCLUSIONS We propose implications for clinical practice and patient management to minimize cerebral ischemia.
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Abstract
Subarachnoid haemorrhage (SAH) is the third most common subtype of stroke. Incidence has decreased over past decades, possibly in part related to lifestyle changes such as smoking cessation and management of hypertension. Approximately a quarter of patients with SAH die before hospital admission; overall outcomes are improved in those admitted to hospital, but with elevated risk of long-term neuropsychiatric sequelae such as depression. The disease continues to have a major public health impact as the mean age of onset is in the mid-fifties, leading to many years of reduced quality of life. The clinical presentation varies, but severe, sudden onset of headache is the most common symptom, variably associated with meningismus, transient or prolonged unconsciousness, and focal neurological deficits including cranial nerve palsies and paresis. Diagnosis is made by CT scan of the head possibly followed by lumbar puncture. Aneurysms are commonly the underlying vascular cause of spontaneous SAH and are diagnosed by angiography. Emergent therapeutic interventions are focused on decreasing the risk of rebleeding (ie, preventing hypertension and correcting coagulopathies) and, most crucially, early aneurysm treatment using coil embolisation or clipping. Management of the disease is best delivered in specialised intensive care units and high-volume centres by a multidisciplinary team. Increasingly, early brain injury presenting as global cerebral oedema is recognised as a potential treatment target but, currently, disease management is largely focused on addressing secondary complications such as hydrocephalus, delayed cerebral ischaemia related to microvascular dysfunction and large vessel vasospasm, and medical complications such as stunned myocardium and hospital acquired infections.
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Affiliation(s)
- Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA.
| | - Soojin Park
- Department of Neurology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
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Grensemann J, Mader MMD, Westphal M, Kluge S, Czorlich P. Hyperoxia is Dose-Dependently Associated with an Increase of Unfavorable Outcomes in Ventilated Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Cohort Study. Neurocrit Care 2022; 37:523-530. [PMID: 35672497 PMCID: PMC9519732 DOI: 10.1007/s12028-022-01534-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/05/2022] [Indexed: 11/05/2022]
Abstract
Background Adequate oxygenation in patients with aneurysmal subarachnoid hemorrhage (SAH) is imperative. However, hyperoxia increases formation of reactive oxygen species and may be associated with a dose-dependent toxicity. We postulated a threshold for arterial partial pressure of oxygen (paO2) above which toxicity effects precipitate and sought to study the effects on 30-day mortality, favorable outcome at discharge and at 3 months, and delayed cerebral ischemia. Methods In this retrospective single-center cohort study, patients with SAH and mechanical ventilation > 72 h were included. Oxygen integrals were calculated above the following thresholds: 80, 100, 120, and 150 mm Hg and time-weighted mean paO2. All calculations were done from admission to end of day 1, day 3, and day 14. We conducted multivariable logistic regression analyses adjusted for age, sex, duration of ventilation, and Hunt and Hess grade. Time-weighted mean paO2 was categorized by quartiles. Favorable outcome was defined as Glasgow Outcome Scale scores of 4 and 5. Results From November 2010 to February 2021, 282 of 549 patients fulfilled the inclusion criteria. Odds ratios for 30-day mortality increased dose dependently and were as follows: 1.07 (95% confidence interval [CI] 1.03–1.11; p = 0.001) for each 1 mm Hg per day above 80 mm Hg; 1.16 (95% CI 1.07–1.27), above 100 mm Hg; 1.36 (95% CI 1.15–1.61), above 120 mm Hg; and 1.59 (95% CI 1.22–2.08), above 150 mm Hg (all p < 0.001) at day 14. For favorable outcome at 3 months, odds ratios were 0.96 (95% CI 0.92–0.99) for each 1 mm Hg per day above 80 mm Hg; 0.90 (95% CI 0.84–0.98), above 100 mm Hg; 0.83 (95% CI 0.72–0.97), above 120 mm Hg; and 0.77 (95% CI 0.61–0.97), above 150 mm Hg (all p < 0.05). For time-weighted mean paO2, lowest 30-day mortality and highest favorable outcome at 3 months were found in the second quartile (78–85 mm Hg). Thirty-day mortality increased above 93 mm Hg (fourth quartile), with an odds ratio of 3.4 (95% CI 1.4–8.4, p = 0.007). Odds ratios for favorable outcome at 3 months were 0.28 (95% CI 0.12–0.69), 0.27 (95% CI 0.11–0.67), and 0.24 (95% CI 0.10–0.59) for the first, third, and fourth quartiles, respectively (all p < 0.01). No significant association was found at day 1 and day 3, for favorable outcome at discharge, or for delayed cerebral ischemia. Conclusions Integrals above the defined paO2 thresholds were dose-dependently associated with an increase in mortality in ventilated patients with SAH. When we considered time-weighted mean paO2, unfavorable outcomes and 30-day mortality were more frequent both below and above a certain range. Unfavorable outcomes increased in paO2 ranges usually defined as normoxia. This emphasizes the necessity to further characterize oxygenation thresholds in ventilated patients with SAH in prospective clinical studies. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-022-01534-y.
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The Effect of Hyperoxemia on Neurological Outcomes of Adult Patients: A Systematic Review and Meta-Analysis. Neurocrit Care 2022; 36:1027-1043. [PMID: 35099713 PMCID: PMC9110471 DOI: 10.1007/s12028-021-01423-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/14/2021] [Indexed: 12/29/2022]
Abstract
Hyperoxemia commonly occurs in clinical practice and is often left untreated. Many studies have shown increased mortality in patients with hyperoxemia, but data on neurological outcome in these patients are conflicting, despite worsened neurological outcome found in preclinical studies. To investigate the association between hyperoxemia and neurological outcome in adult patients, we performed a systematic review and meta-analysis of observational studies. We searched MEDLINE, Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and ClinicalTrials.gov from inception to May 2020 for observational studies correlating arterial oxygen partial pressure (PaO2) with neurological status in adults hospitalized with acute conditions. Studies of chronic pulmonary disease or hyperbaric oxygenation were excluded. Relative risks (RRs) were pooled at the study level by using a random-effects model to compare the risk of poor neurological outcome in patients with hyperoxemia and patients without hyperoxemia. Sensitivity and subgroup analyses and assessments of publication bias and risk of bias were performed. Maximum and mean PaO2 in patients with favorable and unfavorable outcomes were compared using standardized mean difference (SMD). Of 6255 records screened, 32 studies were analyzed. Overall, hyperoxemia was significantly associated with an increased risk of poor neurological outcome (RR 1.13, 95% confidence interval [CI] 1.05-1.23, statistical heterogeneity I2 58.8%, 22 studies). The results were robust across sensitivity analyses. Patients with unfavorable outcome also showed a significantly higher maximum PaO2 (SMD 0.17, 95% CI 0.04-0.30, I2 78.4%, 15 studies) and mean PaO2 (SMD 0.25, 95% CI 0.04-0.45, I2 91.0%, 13 studies). These associations were pronounced in patients with subarachnoid hemorrhage (RR 1.34, 95% CI 1.14-1.56) and ischemic stroke (RR 1.41, 95% CI 1.14-1.74), but not in patients with cardiac arrest, traumatic brain injury, or following cardiopulmonary bypass. Hyperoxemia is associated with poor neurological outcome, especially in patients with subarachnoid hemorrhage and ischemic stroke. Although our study cannot establish causality, PaO2 should be monitored closely because hyperoxemia may be associated with worsened patient outcome and consequently affect the patient's quality of life.
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The Impact of Short-Term Hyperoxia on Cerebral Metabolism: A Systematic Review and Meta-Analysis. Neurocrit Care 2022; 37:547-557. [PMID: 35641804 DOI: 10.1007/s12028-022-01529-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/26/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Cerebral ischemia due to hypoxia is a major cause of secondary brain injury and is associated with higher morbidity and mortality in patients with acute brain injury. Hyperoxia could improve energetic dysfunction in the brain in this setting. Our objectives were to perform a systematic review and meta-analysis of the current literature and to assess the impact of normobaric hyperoxia on brain metabolism by using cerebral microdialysis. METHODS We searched Medline and Scopus, following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement; we searched for retrospective and prospective observational studies, interventional studies, and randomized clinical trials that performed a hyperoxia challenge in patients with acute brain injury who were concomitantly monitored with cerebral microdialysis. This study was registered in PROSPERO (CRD420211295223). RESULTS We included a total of 17 studies, with a total of 311 patients. A statistically significant reduction in cerebral lactate values (pooled standardized mean difference [SMD] - 0.38 [- 0.53 to - 0.23]) and lactate to pyruvate ratio values (pooled SMD - 0.20 [- 0.35 to - 0.05]) was observed after hyperoxia. However, glucose levels (pooled SMD - 0.08 [- 0.23 to 0.08]) remained unchanged after hyperoxia. CONCLUSIONS Normobaric hyperoxia may improve cerebral metabolic disturbances in patients with acute brain injury. The clinical impact of such effects needs to be further elucidated.
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Svedung Wettervik T, Engquist H, Hånell A, Howells T, Rostami E, Ronne-Engström E, Lewén A, Enblad P. Cerebral Blood Flow and Oxygen Delivery in Aneurysmal Subarachnoid Hemorrhage: Relation to Neurointensive Care Targets. Neurocrit Care 2022; 37:281-292. [PMID: 35449343 PMCID: PMC9283361 DOI: 10.1007/s12028-022-01496-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/22/2022] [Indexed: 02/04/2023]
Abstract
Background The primary aim was to determine to what extent continuously monitored neurointensive care unit (neuro-ICU) targets predict cerebral blood flow (CBF) and delivery of oxygen (CDO2) after aneurysmal subarachnoid hemorrhage. The secondary aim was to determine whether CBF and CDO2 were associated with clinical outcome. Methods In this observational study, patients with aneurysmal subarachnoid hemorrhage treated at the neuro-ICU in Uppsala, Sweden, from 2012 to 2020 with at least one xenon-enhanced computed tomography (Xe-CT) obtained within the first 14 days post ictus were included. CBF was measured with the Xe-CT and CDO2 was calculated based on CBF and arterial oxygen content. Regional cerebral hypoperfusion was defined as CBF < 20 mL/100 g/min, and poor CDO2 was defined as CDO2 < 3.8 mL O2/100 g/min. Neuro-ICU variables including intracranial pressure (ICP), pressure reactivity index, cerebral perfusion pressure (CPP), optimal CPP, and body temperature were assessed in association with the Xe-CT. The acute phase was divided into early phase (day 1–3) and vasospasm phase (day 4–14). Results Of 148 patients, 27 had underwent a Xe-CT only in the early phase, 74 only in the vasospasm phase, and 47 patients in both phases. The patients exhibited cerebral hypoperfusion and poor CDO2 for medians of 15% and 30%, respectively, of the cortical brain areas in each patient. In multiple regressions, higher body temperature was associated with higher CBF and CDO2 in the early phase. In a similar regression for the vasospasm phase, younger age and longer pulse transit time (lower peripheral resistance) correlated with higher CBF and CDO2, whereas lower hematocrit only correlated with higher CBF but not with CDO2. ICP, CPP, and pressure reactivity index exhibited no independent association with CBF and CDO2. R2 of these regressions were below 0.3. Lower CBF and CDO2 in the early phase correlated with poor outcome, but this only held true for CDO2 in multiple regressions. Conclusions Systemic and cerebral physiological variables exhibited a modest association with CBF and CDO2. Still, cerebral hypoperfusion and low CDO2 were common and low CDO2 was associated with poor outcome. Xe-CT imaging could be useful to help detect secondary brain injury not evident by high ICP and low CPP. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-022-01496-1.
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Affiliation(s)
| | - Henrik Engquist
- Department of Surgical Sciences/Anesthesia and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Anders Hånell
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Timothy Howells
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Elham Rostami
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | | | - Anders Lewén
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden
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16
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Francoeur CL, Lauzier F, Brassard P, Turgeon AF. Near Infrared Spectroscopy for Poor Grade Aneurysmal Subarachnoid Hemorrhage-A Concise Review. Front Neurol 2022; 13:874393. [PMID: 35518206 PMCID: PMC9062216 DOI: 10.3389/fneur.2022.874393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Delayed cerebral ischemia (DCI) disproportionately affects poor grade aneurysmal subarachnoid hemorrhage (aSAH) patients. An unreliable neurological exam and the lack of appropriate monitoring leads to unrecognized DCI, which in turn is associated with severe long-term deficits and higher mortality. Near Infrared Spectroscopy (NIRS) offers simple, continuous, real time, non-invasive cerebral monitoring. It provides regional cerebral oxygen saturation (c-rSO2), which reflects the balance between cerebral oxygen consumption and supply. Reports have demonstrated a good correlation with other cerebral oxygen and blood flow monitoring, and credible cerebrovascular reactivity indices were also derived from NIRS signals. Multiple critical c-rSO2 values have been reported in aSAH patients, based on various thresholds, duration, variation from baseline or cerebrovascular reactivity indices. Some were associated with vasospasm, some with DCI and others with clinical outcomes. However, the poor grade aSAH population has not been specifically studied and no randomized clinical trial has been published. The available literature does not support a specific NIRS-based intervention threshold to guide diagnostic or treatment in aSAH patients. We review herein the fundamental basic concepts behind NIRS technology, relationship of c-rSO2 to other brain monitoring values and their potential clinical interpretation. We follow with a critical evaluation of the use of NIRS in the aSAH population, more specifically its ability to diagnose vasospasm, to predict DCI and its association to outcome. In summary, NIRS might offer significant potential for poor grade aSAH in the future. However, current evidence does not support its use in clinical decision-making, and proper technology evaluation is required.
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Affiliation(s)
- Charles L. Francoeur
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), Centre Hospitalier Universitaire (CHU) de Québec—Université Laval Research Centre, Université Laval, Québec City, QC, Canada
- Department of Anesthesiology and Critical Care, CHU de Québec—Université Laval, Critical Care Division, Québec City, QC, Canada
- Critical Care Medicine Service, CHU de Québec—Université Laval, Québec City, QC, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), Centre Hospitalier Universitaire (CHU) de Québec—Université Laval Research Centre, Université Laval, Québec City, QC, Canada
- Department of Anesthesiology and Critical Care, CHU de Québec—Université Laval, Critical Care Division, Québec City, QC, Canada
- Critical Care Medicine Service, CHU de Québec—Université Laval, Québec City, QC, Canada
| | - Patrice Brassard
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec City, QC, Canada
- Research Center of the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, QC, Canada
| | - Alexis F. Turgeon
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), Centre Hospitalier Universitaire (CHU) de Québec—Université Laval Research Centre, Université Laval, Québec City, QC, Canada
- Department of Anesthesiology and Critical Care, CHU de Québec—Université Laval, Critical Care Division, Québec City, QC, Canada
- Critical Care Medicine Service, CHU de Québec—Université Laval, Québec City, QC, Canada
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17
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Ahn J, Mastorakos P, Sokolowski JD, Chen CJ, Kellogg R, Park MS. Effects of hyperoxemia on aneurysmal subarachnoid hemorrhage outcomes: a systematic review and meta-analysis. Neurosurg Focus 2022; 52:E7. [PMID: 35231897 DOI: 10.3171/2021.12.focus21660] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/10/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE In recent years, hyperoxemia in the intensive care unit has received attention as potentially contributing to negative outcomes in the setting of cardiac arrest, ischemic stroke, and traumatic brain injury. The authors sought to evaluate whether hyperoxemia contributes to worse outcomes in the setting of aneurysmal subarachnoid hemorrhage (aSAH) and to summarize suggested pathophysiological mechanisms. METHODS A systematic literature review was conducted without date restrictions on the PubMed and Web of Science databases on September 15, 2021. All studies that assessed the relationship between patients treated for aSAH and hyperoxemia were eligible independent of the criteria used to define hyperoxemia. All nonclinical studies and studies that did not report outcome data specific to patients with aSAH were excluded. A total of 102 records were found and screened, resulting in assessment of 10 full-text studies, of which 7 met eligibility criteria. Risk of bias was assessed using the Downs and Black checklist. A meta-analysis on the pooled 2602 patients was performed, and forest plots were constructed. Additionally, a review of the literature was performed to summarize available data regarding the pathophysiology of hyperoxemia. RESULTS The included studies demonstrated an association between hyperoxemia and increased morbidity and mortality following aSAH. The criteria used to determine hyperoxemia varied among studies. Pooling of univariate data showed hyperoxemia to be associated with poor neurological outcome (OR 2.26, 95% CI 1.66-3.07; p < 0.001), delayed cerebral ischemia (DCI) (OR 1.91, 95% CI 1.31-2.78; p < 0.001), and increased incidence of poor neurological outcome or mortality as a combined endpoint (OR 2.36, 95% CI 1.87-2.97; p < 0.001). Pooling of multivariable effect sizes showed the same relationship for poor neurological outcome (OR 1.28, 95% CI 1.07-1.55; p = 0.01) and poor neurological outcome and mortality as a combined endpoint (OR 1.17, 95% CI 1.11-1.23; p < 0.001). Additionally, review of preclinical studies underlined the contribution of oxidative stress due to hyperoxemia to acute secondary brain injury and DCI. CONCLUSIONS Reported outcomes from the available studies have indicated that hyperoxemia is associated with worse neurological outcome, mortality, and DCI. These findings provide a general guideline toward avoiding hyperoxemia in the acute setting of aSAH. Further studies are needed to determine the optimal ventilation and oxygenation parameters for acute management of this patient population.
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Affiliation(s)
- Jungeun Ahn
- 1School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Panagiotis Mastorakos
- 2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Jennifer D Sokolowski
- 2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Ching-Jen Chen
- 3Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ryan Kellogg
- 2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Min S Park
- 2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
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18
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Svedung Wettervik T, Hånell A, Howells T, Ronne-Engström E, Enblad P, Lewén A. Association of Arterial Metabolic Content with Cerebral Blood Flow Regulation and Cerebral Energy Metabolism-A Multimodality Analysis in Aneurysmal Subarachnoid Hemorrhage. J Intensive Care Med 2022; 37:1442-1450. [PMID: 35171061 PMCID: PMC9548938 DOI: 10.1177/08850666221080054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background In this study, the association of the arterial content of oxygen, carbon
dioxide, glucose, and lactate with cerebral pressure reactivity, energy
metabolism and clinical outcome after aneurysmal subarachnoid hemorrhage
(aSAH) was investigated. Methods In this retrospective study, 60 patients with aSAH, treated at the
neurointensive care (NIC), Uppsala University Hospital, Sweden, between 2016
and 2021 with arterial blood gas (ABG), intracranial pressure, and cerebral
microdialysis (MD) monitoring were included. The first 10 days were divided
into an early phase (day 1 to 3) and a vasospasm phase (day 4 to 10). Results Higher arterial lactate was independently associated with higher/worse
pressure reactivity index (PRx) in the early phase (β = 0.32,
P = .02), whereas higher pO2 had the
opposite association in the vasospasm phase (β = −0.30,
P = .04). Arterial glucose and pCO2 were not
associated with PRx. Higher arterial lactate (β = 0.29,
P = .05) was independently associated with higher
MD-glucose in the vasospasm phase, whereas higher pO2 had the
opposite association in the vasospasm phase (β = −0.33,
P = .03). Arterial glucose and pCO2 were not
associated with MD-glucose. Higher pCO2 in the early phase, lower
arterial glucose in both phases, and lower arterial lactate in the vasospasm
phase were associated (P < .05) with better clinical
outcome. Conclusions Arterial variables associated with more vasoconstriction (higher
pO2 and lower arterial lactate) were associated with better
cerebral pressure reactivity, but worse energy metabolism. In severe aSAH,
when cerebral large-vessel vasospasm with exhausted distal vasodilation is
common, more vasoconstriction could increase distal vasodilatory reserve and
pressure reactivity, but also reduce cerebral blood flow and metabolic
supply. The MD may be useful to monitor the net effects on cerebral
metabolism in PRx-targeted NIC.
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Barnett HM, Davis AP, Khot SP. Stroke and breathing. HANDBOOK OF CLINICAL NEUROLOGY 2022; 189:201-222. [PMID: 36031305 DOI: 10.1016/b978-0-323-91532-8.00016-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Stroke remains a leading cause of neurologic disability with wide ranging effects, including a variety of respiratory abnormalities. Stroke may influence the central control of the respiratory drive and breathing pattern, airway protection and maintenance, and the respiratory mechanics of inspiration and expiration. In the acute phase of stroke, the central control of breathing is affected by changes in consciousness, cerebral edema, and direct damage to brainstem respiratory centers, resulting in abnormalities in respiratory pattern and loss of airway protection. Common acute complications related to respiratory dysfunction include dysphagia, aspiration, and pneumonia. Respiratory control centers are located in the brainstem, and brainstem stroke causes specific patterns of respiratory dysfunction. Depending on the exact location and extent of stroke, respiratory failure may occur. While major respiratory abnormalities often improve over time, sleep-disordered breathing remains common in the subacute and chronic phases and worsens outcomes. Respiratory mechanics are impaired in hemiplegic or hemiparetic stroke, contributing to worse cardiopulmonary health in stroke survivors. Interventions to address the respiratory complications are under researched, and further investigation in this area is critical to improving outcomes among stroke survivors.
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Affiliation(s)
- Heather M Barnett
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
| | - Arielle P Davis
- Department of Neurology, University of Washington, Seattle, WA, United States
| | - Sandeep P Khot
- Department of Neurology, University of Washington, Seattle, WA, United States.
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Gottlieb J, Capetian P, Hamsen U, Janssens U, Karagiannidis C, Kluge S, Nothacker M, Roiter S, Volk T, Worth H, Fühner T. German S3 Guideline: Oxygen Therapy in the Acute Care of Adult Patients. Respiration 2021; 101:214-252. [PMID: 34933311 DOI: 10.1159/000520294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Oxygen (O2) is a drug with specific biochemical and physiological properties, a range of effective doses and may have side effects. In 2015, 14% of over 55,000 hospital patients in the UK were using oxygen. 42% of patients received this supplemental oxygen without a valid prescription. Health care professionals are frequently uncertain about the relevance of hypoxemia and have low awareness about the risks of hyperoxemia. Numerous randomized controlled trials about targets of oxygen therapy have been published in recent years. A national guideline is urgently needed. METHODS A national S3 guideline was developed and published within the Program for National Disease Management Guidelines (AWMF) with participation of 10 medical associations. A literature search was performed until February 1, 2021, to answer 10 key questions. The Oxford Centre for Evidence-Based Medicine (CEBM) System ("The Oxford 2011 Levels of Evidence") was used to classify types of studies in terms of validity. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the quality of evidence and for grading guideline recommendation, and a formal consensus-building process was performed. RESULTS The guideline includes 34 evidence-based recommendations about indications, prescription, monitoring and discontinuation of oxygen therapy in acute care. The main indication for O2 therapy is hypoxemia. In acute care both hypoxemia and hyperoxemia should be avoided. Hyperoxemia also seems to be associated with increased mortality, especially in patients with hypercapnia. The guideline provides recommended target oxygen saturation for acute medicine without differentiating between diagnoses. Target ranges for oxygen saturation are based depending on ventilation status risk for hypercapnia. The guideline provides an overview of available oxygen delivery systems and includes recommendations for their selection based on patient safety and comfort. CONCLUSION This is the first national guideline on the use of oxygen in acute care. It addresses health care professionals using oxygen in acute out-of-hospital and in-hospital settings.
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Affiliation(s)
- Jens Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Philipp Capetian
- Department of Neurology, University Hospital Würzburg, Wuerzburg, Germany
| | - Uwe Hamsen
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St. Antonius Hospital, Eschweiler, Germany
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln, Witten/Herdecke University Hospital, Cologne, Germany
| | - Stefan Kluge
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Monika Nothacker
- AWMF-Institute for Medical Knowledge Management, Marburg, Germany
| | - Sabrina Roiter
- Intensive Care Unit, Israelite Hospital Hamburg, Hamburg, Germany
| | - Thomas Volk
- Department of Anesthesiology, University Hospital of Saarland, Saarland University, Homburg, Germany
| | | | - Thomas Fühner
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany.,Department of Respiratory Medicine, Siloah Hospital, Hannover, Germany
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21
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Busani S, Sarti M, Serra F, Gelmini R, Venturelli S, Munari E, Girardis M. Revisited Hyperoxia Pathophysiology in the Perioperative Setting: A Narrative Review. Front Med (Lausanne) 2021; 8:689450. [PMID: 34746165 PMCID: PMC8569225 DOI: 10.3389/fmed.2021.689450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 09/22/2021] [Indexed: 01/05/2023] Open
Abstract
The widespread use of high-dose oxygen, to avoid perioperative hypoxemia along with WHO-recommended intraoperative hyperoxia to reduce surgical site infections, is an established clinical practice. However, growing pathophysiological evidence has demonstrated that hyperoxia exerts deleterious effects on many organs, mainly mediated by reactive oxygen species. The purpose of this narrative review was to present the pathophysiology of perioperative hyperoxia on surgical wound healing, on systemic macro and microcirculation, on the lungs, heart, brain, kidneys, gut, coagulation, and infections. We reported here that a high systemic oxygen supply could induce oxidative stress with inflammation, vasoconstriction, impaired microcirculation, activation of hemostasis, acute and chronic lung injury, coronary blood flow disturbances, cerebral ischemia, surgical anastomosis impairment, gut dysbiosis, and altered antibiotics susceptibility. Clinical studies have provided rather conflicting results on the definitions and outcomes of hyperoxic patients, often not speculating on the biological basis of their results, while this review highlighted what happens when supranormal PaO2 values are reached in the surgical setting. Based on the assumptions analyzed in this study, we may suggest that the maintenance of PaO2 within physiological ranges, avoiding unnecessary oxygen administration, may be the basis for good clinical practice.
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Affiliation(s)
- Stefano Busani
- Cattedra e Servizio di Anestesia e Rianimazione, Azienda Universitaria Policlinico di Modena, Modena, Italy
| | - Marco Sarti
- Cattedra e Servizio di Anestesia e Rianimazione, Azienda Universitaria Policlinico di Modena, Modena, Italy
| | - Francesco Serra
- Chirurgia Generale d'Urgenza e Oncologica, Azienda Universitaria Policlinico di Modena, Modena, Italy
| | - Roberta Gelmini
- Chirurgia Generale d'Urgenza e Oncologica, Azienda Universitaria Policlinico di Modena, Modena, Italy
| | - Sophie Venturelli
- Cattedra e Servizio di Anestesia e Rianimazione, Azienda Universitaria Policlinico di Modena, Modena, Italy
| | - Elena Munari
- Chirurgia Generale d'Urgenza e Oncologica, Azienda Universitaria Policlinico di Modena, Modena, Italy
| | - Massimo Girardis
- Cattedra e Servizio di Anestesia e Rianimazione, Azienda Universitaria Policlinico di Modena, Modena, Italy
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22
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Cai G, Ru W, Xu Q, Wu J, Gong S, Yan J, Shen Y. Association Between Oxygen Partial Pressure Trajectories and Short-Term Outcomes in Patients With Hemorrhagic Brain Injury. Front Med (Lausanne) 2021; 8:681200. [PMID: 34568355 PMCID: PMC8458649 DOI: 10.3389/fmed.2021.681200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 08/10/2021] [Indexed: 11/29/2022] Open
Abstract
Objectives: Arterial hyperoxia is reportedly a risk factor for poor outcomes in patients with hemorrhagic brain injury (HBI). However, most previous studies have only evaluated the effects of hyperoxia using static oxygen partial pressure (PaO2) values. This study aimed to investigate the association between overall dynamic oxygenation status and HBI outcomes, using longitudinal PaO2 data. Methods: Data were extracted from the Medical Information Mart for Intensive Care III database. Longitudinal PaO2 data obtained within 72 h of admission to an intensive care unit were analyzed, using a group-based trajectory approach. In-hospital mortality was used as the primary outcomes. Multivariable logistic models were used to explore the association between PaO2 trajectory and outcomes. Results: Data of 2,028 patients with HBI were analyzed. Three PaO2 trajectory types were identified: Traj-1 (mild hyperoxia), Traj-2 (transient severe hyperoxia), and Traj-3 (persistent severe hyperoxia). The initial and maximum PaO2 of patients with Traj-2 and Traj-3 were similar and significantly higher than those of patients with Traj-1. However, PaO2 in patients with Traj-2 decreased more rapidly than in patients with Traj-3. The crude in-hospital mortality was the lowest for patients with Traj-1 and highest for patients with Traj-3 (365/1,303, 209/640, and 43/85 for Traj-1, Traj-2, and Traj-3, respectively; p < 0.001), and the mean Glasgow Coma Scale score at discharge (GCSdis) was highest for patients with Traj-1 and lowest in patients with Traj-3 (13 [7–15], 11 [6–15], and 7 [3–14] for Traj-1, Traj-2, and Traj-3, respectively; p < 0.001). The multivariable model revealed that the risk of death was higher in patients with Traj-3 than in patients with Traj-1 (odds ratio [OR]: 3.3, 95% confidence interval [CI]: 1.9–5.8) but similar for patients with Traj-1 and Traj-2. Similarly, the logistic analysis indicated the worst neurological outcomes in patients with Traj-3 (OR: 3.6, 95% CI: 2.0–6.4, relative to Traj-1), but similar neurological outcomes for patients in Traj-1 and Traj-2. Conclusion: Persistent, but not transient severe arterial hyperoxia, was associated with poor outcome in patients with HBI.
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Affiliation(s)
- Guolong Cai
- Department of Intensive Care, Zhejiang Hospital, Hangzhou, China
| | - Weizhe Ru
- Department of Oncology, Cixi People's Hospital, Cixi, China
| | - Qianghong Xu
- Department of Intensive Care, Zhejiang Hospital, Hangzhou, China
| | - Jiong Wu
- Department of Neurology, Zhejiang Hospital, Hangzhou, China
| | - Shijin Gong
- Department of Intensive Care, Zhejiang Hospital, Hangzhou, China
| | - Jing Yan
- Department of Intensive Care, Zhejiang Hospital, Hangzhou, China
| | - Yanfei Shen
- Department of Intensive Care, Zhejiang Hospital, Hangzhou, China
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23
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Gottlieb J, Capetian P, Hamsen U, Janssens U, Karagiannidis C, Kluge S, König M, Markewitz A, Nothacker M, Roiter S, Unverzagt S, Veit W, Volk T, Witt C, Wildenauer R, Worth H, Fühner T. [German S3 Guideline - Oxygen Therapy in the Acute Care of Adult Patients]. Pneumologie 2021; 76:159-216. [PMID: 34474487 DOI: 10.1055/a-1554-2625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Oxygen (O2) is a drug with specific biochemical and physiologic properties, a range of effective doses and may have side effects. In 2015, 14 % of over 55 000 hospital patients in the UK were using oxygen. 42 % of patients received this supplemental oxygen without a valid prescription. Healthcare professionals are frequently uncertain about the relevance of hypoxemia and have low awareness about the risks of hyperoxemia. Numerous randomized controlled trials about targets of oxygen therapy have been published in recent years. A national guideline is urgently needed. METHODS A S3-guideline was developed and published within the Program for National Disease Management Guidelines (AWMF) with participation of 10 medical associations. Literature search was performed until Feb 1st 2021 to answer 10 key questions. The Oxford Centre for Evidence-Based Medicine (CEBM) System ("The Oxford 2011 Levels of Evidence") was used to classify types of studies in terms of validity. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used and for assessing the quality of evidence and for grading guideline recommendation and a formal consensus-building process was performed. RESULTS The guideline includes 34 evidence-based recommendations about indications, prescription, monitoring and discontinuation of oxygen therapy in acute care. The main indication for O2 therapy is hypoxemia. In acute care both hypoxemia and hyperoxemia should be avoided. Hyperoxemia also seems to be associated with increased mortality, especially in patients with hypercapnia. The guideline provides recommended target oxygen saturation for acute medicine without differentiating between diagnoses. Target ranges for oxygen saturation are depending on ventilation status risk for hypercapnia. The guideline provides an overview of available oxygen delivery systems and includes recommendations for their selection based on patient safety and comfort. CONCLUSION This is the first national guideline on the use of oxygen in acute care. It addresses healthcare professionals using oxygen in acute out-of-hospital and in-hospital settings. The guideline will be valid for 3 years until June 30, 2024.
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Affiliation(s)
- Jens Gottlieb
- Klinik für Pneumologie, Medizinische Hochschule Hannover.,Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH) im Deutschen Zentrum für Lungenforschung (DZL)
| | - Philipp Capetian
- Klinik für Neurologie, Neurologische Intensivstation, Universitätsklinikum Würzburg
| | - Uwe Hamsen
- Fachbereich für Unfallchirurgie und Orthopädie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum
| | - Uwe Janssens
- Innere Medizin und internistische Intensivmedizin, Sankt Antonius Hospital GmbH, Eschweiler
| | - Christian Karagiannidis
- Abteilung für Pneumologie und Beatmungsmedizin, ARDS/ECMO Zentrum, Lungenklinik Köln-Merheim
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Eppendorf, Hamburg
| | - Marco König
- Deutscher Berufsverband Rettungsdienst e. V., Lübeck
| | - Andreas Markewitz
- ehem. Klinik für Herz- und Gefäßchirurgie Bundeswehrzentralkrankenhaus Koblenz
| | - Monika Nothacker
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V., Marburg
| | | | | | - Wolfgang Veit
- Bundesverband der Organtransplantierten e. V., Marne
| | - Thomas Volk
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Homburg/Saar
| | - Christian Witt
- Seniorprofessor Innere Medizin und Pneumologie, Charité Berlin
| | | | | | - Thomas Fühner
- Krankenhaus Siloah, Klinik für Pneumologie und Beatmungsmedizin, Klinikum Region Hannover.,Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH) im Deutschen Zentrum für Lungenforschung (DZL)
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24
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Zheng S, Wang H, Chen G, Shangguan H, Yu L, Lin Z, Lin Y, Yao P, Kang D. Higher Serum Levels of Lactate Dehydrogenase Before Microsurgery Predict Poor Outcome of Aneurysmal Subarachnoid Hemorrhage. Front Neurol 2021; 12:720574. [PMID: 34456854 PMCID: PMC8387557 DOI: 10.3389/fneur.2021.720574] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 07/19/2021] [Indexed: 02/03/2023] Open
Abstract
Introduction: We explored whether higher preoperative serum levels of lactate dehydrogenase (LDH) predicted outcome 3 months after surgery in patients with aneurysmal subarachnoid hemorrhage (aSAH) treated using microsurgical clipping in our institution. Methods: Patients with aSAH treated at our institution between 2010 and 2018 were enrolled. The following parameters were recorded: age, sex, smoking and drinking history, medical history, Hunt–Hess and Fisher grades, aneurysm location, aneurysm size, surgical treatment, delayed cerebral ischemia (DCI), intracranial infection, hydrocephalus, pneumonia, and preoperative serum LDH levels within 24 h of aSAH. We investigated whether preoperative serum LDH levels were associated with Hunt–Hess grade, Fisher grade, and functional neurological outcome. Results: In total, 2,054 patients with aSAH were enrolled, 874 of whom were treated using microsurgical clipping. The average serum LDH level (U/L) was significantly lower in the good outcome group (180.096 ± 50.237) than in the poor outcome group (227.554 ± 83.002; p < 0.001). After propensity score matching, the average serum LDH level (U/L) was still lower in the good outcome group (205.356 ± 76.785) than in the poor outcome group (227.119 ± 86.469; p = 0.029). The area under the receiver operating characteristic (ROC) curve was 0.702 (95% confidence interval [CI]: 0.650–0.754; p < 0.001). Based on the ROC curve, the optimal cutoff value for serum LDH levels as a predictor of poor 3-month outcome (modified Rankin Scale score > 2) was 201.5 U/L. The results revealed that Hunt–Hess grade, Fisher grade, DCI, pneumonia, and serum LDH (>201.5 U/L) were significantly associated with poor outcome. After propensity score matching, serum LDH levels > 201.5 U/L were still considered an independent risk factor for poor outcome (odds ratio: 2.426, 95% CI = 1.378–4.271, p = 0.002). Serum LDH levels were associated with Hunt–Hess and Fisher grades and were correlated with functional neurological outcomes (p < 0.001). Conclusions: Our findings showed that higher preoperative serum levels of LDH correlated with Hunt–Hess grade, Fisher grade, and neurological functional outcome, and predicted the outcome of aSAH treated by microsurgical clipping at 3 months, which was involved in the related mechanisms of early brain injury and showed its potential clinical significance in patients with aSAH.
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Affiliation(s)
- Shufa Zheng
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Haojie Wang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Guorong Chen
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Huangcheng Shangguan
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Lianghong Yu
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Zhangya Lin
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yuanxiang Lin
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Peisen Yao
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Dezhi Kang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Precision Medicine for Cancer, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Key Laboratory of Radiation Biology of Fujian Higher Education Institutions, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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25
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Demiselle J, Calzia E, Hartmann C, Messerer DAC, Asfar P, Radermacher P, Datzmann T. Target arterial PO 2 according to the underlying pathology: a mini-review of the available data in mechanically ventilated patients. Ann Intensive Care 2021; 11:88. [PMID: 34076802 PMCID: PMC8170650 DOI: 10.1186/s13613-021-00872-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/10/2021] [Indexed: 12/15/2022] Open
Abstract
There is an ongoing discussion whether hyperoxia, i.e. ventilation with high inspiratory O2 concentrations (FIO2), and the consecutive hyperoxaemia, i.e. supraphysiological arterial O2 tensions (PaO2), have a place during the acute management of circulatory shock. This concept is based on experimental evidence that hyperoxaemia may contribute to the compensation of the imbalance between O2 supply and requirements. However, despite still being common practice, its use is limited due to possible oxygen toxicity resulting from the increased formation of reactive oxygen species (ROS) limits, especially under conditions of ischaemia/reperfusion. Several studies have reported that there is a U-shaped relation between PaO2 and mortality/morbidity in ICU patients. Interestingly, these mostly retrospective studies found that the lowest mortality coincided with PaO2 ~ 150 mmHg during the first 24 h of ICU stay, i.e. supraphysiological PaO2 levels. Most of the recent large-scale retrospective analyses studied general ICU populations, but there are major differences according to the underlying pathology studied as well as whether medical or surgical patients are concerned. Therefore, as far as possible from the data reported, we focus on the need of mechanical ventilation as well as the distinction between the absence or presence of circulatory shock. There seems to be no ideal target PaO2 except for avoiding prolonged exposure (> 24 h) to either hypoxaemia (PaO2 < 55-60 mmHg) or supraphysiological (PaO2 > 100 mmHg). Moreover, the need for mechanical ventilation, absence or presence of circulatory shock and/or the aetiology of tissue dysoxia, i.e. whether it is mainly due to impaired macro- and/or microcirculatory O2 transport and/or disturbed cellular O2 utilization, may determine whether any degree of hyperoxaemia causes deleterious side effects.
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Affiliation(s)
- Julien Demiselle
- Service de Médecine Intensive - Réanimation, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, 1, place de l′Hôpital, F–67091, Strasbourg, Cedex, France
| | - Enrico Calzia
- Institut Für Anästhesiologische Pathophysiologie Und Verfahrensentwicklung, Universitätsklinikum, Helmholtzstrasse 8-1, 89081 Ulm, Germany
| | - Clair Hartmann
- Klinik Für Anästhesiologie Und Intensivmedizin, Universitätsklinikum, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - David Alexander Christian Messerer
- Institut Für Anästhesiologische Pathophysiologie Und Verfahrensentwicklung, Universitätsklinikum, Helmholtzstrasse 8-1, 89081 Ulm, Germany
- Klinik Für Anästhesiologie Und Intensivmedizin, Universitätsklinikum, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Pierre Asfar
- Service de Médecine Intensive - Réanimation Et Médecine Hyperbare, Centre Hospitalier Universitaire D’Angers, 4 rue Larrey - 49 933, Angers Cedex 9, France
| | - Peter Radermacher
- Institut Für Anästhesiologische Pathophysiologie Und Verfahrensentwicklung, Universitätsklinikum, Helmholtzstrasse 8-1, 89081 Ulm, Germany
| | - Thomas Datzmann
- Institut Für Anästhesiologische Pathophysiologie Und Verfahrensentwicklung, Universitätsklinikum, Helmholtzstrasse 8-1, 89081 Ulm, Germany
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26
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Humaloja J, Skrifvars MB, Raj R, Wilkman E, Pekkarinen PT, Bendel S, Reinikainen M, Litonius E. The Association Between Arterial Oxygen Level and Outcome in Neurocritically Ill Patients is not Affected by Blood Pressure. Neurocrit Care 2021; 34:413-422. [PMID: 33403587 PMCID: PMC8128839 DOI: 10.1007/s12028-020-01178-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/04/2020] [Indexed: 11/27/2022]
Abstract
Background In neurocritically ill patients, one early mechanism behind secondary brain injury is low systemic blood pressure resulting in inadequate cerebral perfusion and consequent hypoxia. Intuitively, higher partial pressures of arterial oxygen (PaO2) could be protective in case of inadequate cerebral circulation related to hemodynamic instability. Study purpose We examined whether the association between PaO2 and mortality is different in patients with low compared to normal and high mean arterial pressure (MAP) in patients after various types of brain injury. Methods We screened the Finnish Intensive Care Consortium database for mechanically ventilated adult (≥ 18) brain injury patients treated in several tertiary intensive care units (ICUs) between 2003 and 2013. Admission diagnoses included traumatic brain injury, cardiac arrest, subarachnoid and intracranial hemorrhage, and acute ischemic stroke. The primary exposures of interest were PaO2 (recorded in connection with the lowest measured PaO2/fraction of inspired oxygen ratio) and the lowest MAP, recorded during the first 24 h in the ICU. PaO2 was grouped as follows: hypoxemia (< 8.2 kPa, the lowest 10th percentile), normoxemia (8.2–18.3 kPa), and hyperoxemia (> 18.3 kPa, the highest 10th percentile), and MAP was divided into equally sized tertiles (< 60, 60–68, and > 68 mmHg). The primary outcome was 1-year mortality. We tested the association between hyperoxemia, MAP, and mortality with a multivariable logistic regression model, including the PaO2, MAP, and interaction of PaO2*MAP, adjusting for age, admission diagnosis, premorbid physical performance, vasoactive use, intracranial pressure monitoring use, and disease severity. The relationship between predicted 1-year mortality and PaO2 was visualized with locally weighted scatterplot smoothing curves (Loess) for different MAP levels. Results From a total of 8290 patients, 3912 (47%) were dead at 1 year. PaO2 was not an independent predictor of mortality: the odds ratio (OR) for hyperoxemia was 1.16 (95% CI 0.85–1.59) and for hypoxemia 1.24 (95% CI 0.96–1.61) compared to normoxemia. Higher MAP predicted lower mortality: OR for MAP 60–68 mmHg was 0.73 (95% CI 0.64–0.84) and for MAP > 68 mmHg 0.80 (95% CI 0.69–0.92) compared to MAP < 60 mmHg. The interaction term PaO2*MAP was nonsignificant. In Loess visualization, the relationship between PaO2 and predicted mortality appeared similar in all MAP tertiles. Conclusions During the first 24 h of ICU treatment in mechanically ventilated brain injured patients, the association between PaO2 and mortality was not different in patients with low compared to normal MAP. Supplementary Information The online version of this article (10.1007/s12028-020-01178-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jaana Humaloja
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Erika Wilkman
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pirkka T Pekkarinen
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Stepani Bendel
- Department of Anesthesiology and Intensive Care, Kuopio University Hospital & University of Eastern Finland, Kuopio, Finland
| | - Matti Reinikainen
- Department of Anesthesiology and Intensive Care, Kuopio University Hospital & University of Eastern Finland, Kuopio, Finland
| | - Erik Litonius
- Division of Anesthesiology, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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27
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Robba C, Battaglini D, Samary CS, Silva PL, Ball L, Rocco PRM, Pelosi P. Ischaemic stroke-induced distal organ damage: pathophysiology and new therapeutic strategies. Intensive Care Med Exp 2020; 8:23. [PMID: 33336314 PMCID: PMC7746424 DOI: 10.1186/s40635-020-00305-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/20/2020] [Indexed: 01/09/2023] Open
Abstract
Acute ischaemic stroke is associated with a high risk of non-neurological complications, which include respiratory failure, cardiovascular dysfunction, kidney and liver injury, and altered immune and endocrine function. The aim of this manuscript is to provide an overview of the main forms of stroke-induced distal organ damage, providing new pathophysiological insights and recommendations for clinical management.Non-neurological complications of stroke can affect outcomes, with potential for serious short-term and long-term consequences. Many of these complications can be prevented; when prevention is not feasible, early detection and proper management can still be effective in mitigating their adverse impact. The general care of stroke survivors entails not only treatment in the acute setting but also prevention of secondary complications that might hinder functional recovery. Acute ischaemic stroke triggers a cascade of events-including local and systemic activation of the immune system-which results in a number of systemic consequences and, ultimately, may cause organ failure. Understanding the pathophysiology and clinical relevance of non-neurological complications is a crucial component in the proper treatment of patients with acute stroke.Little evidence-based data is available to guide management of these complications. There is a clear need for improved surveillance and specific interventions for the prevention, early diagnosis, and proper management of non-neurological complications during the acute phase of ischaemic stroke, which should reduce morbidity and mortality.
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Affiliation(s)
- Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Largo Rosanna Benzi 10, 16100, Genoa, Italy.
| | - Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Largo Rosanna Benzi 10, 16100, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Cynthia S Samary
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro L Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Lorenzo Ball
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Largo Rosanna Benzi 10, 16100, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Largo Rosanna Benzi 10, 16100, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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28
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Nakane M. Biological effects of the oxygen molecule in critically ill patients. J Intensive Care 2020; 8:95. [PMID: 33317639 PMCID: PMC7734465 DOI: 10.1186/s40560-020-00505-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 11/10/2020] [Indexed: 02/06/2023] Open
Abstract
The medical use of oxygen has been widely and frequently proposed for patients, especially those under critical care; however, its benefit and drawbacks remain controversial for certain conditions. The induction of oxygen therapy is commonly considered for either treating or preventing hypoxia. Therefore, the concept of different types of hypoxia should be understood, particularly in terms of their mechanism, as the effect of oxygen therapy principally varies by the physiological characteristics of hypoxia. Oxygen molecules must be constantly delivered to all cells throughout the human body and utilized effectively in the process of mitochondrial oxidative phosphorylation, which is necessary for generating energy through the formation of adenosine triphosphate. If the oxygen availability at the cellular level is inadequate for sustaining the metabolism, the condition of hypoxia which is characterized as heterogeneity in tissue oxygen tension may develop, which is called dysoxia, a more physiological concept that is related to hypoxia. In such hypoxic patients, repetitive measurements of the lactate level in blood are generally recommended in order to select the adequate therapeutic strategy targeting a reduction in lactate production. Excessive oxygen, however, may actually induce a hyperoxic condition which thus can lead to harmful oxidative stress by increasing the production of reactive oxygen species, possibly resulting in cellular dysfunction or death. In contrast, the human body has several oxygen-sensing mechanisms for preventing both hypoxia and hyperoxia that are employed to ensure a proper balance between the oxygen supply and demand and prevent organs and cells from suffering hyperoxia-induced oxidative stress. Thus, while the concept of hyperoxia is known to have possible adverse effects on the lung, the heart, the brain, or other organs in various pathological conditions of critically ill patients, and no obvious evidence has yet been proposed to totally support liberal oxygen supplementation in any subset of critically ill patients, relatively conservative oxygen therapy with cautious monitoring appears to be safe and may improve the outcome by preventing harmful oxidative stress resulting from excessive oxygen administration. Given the biological effects of oxygen molecules, although the optimal target levels remain controversial, unnecessary oxygen administration should be avoided, and exposure to hyperoxemia should be minimized in critically ill patients.
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Affiliation(s)
- Masaki Nakane
- Department of Emergency and Critical Care Medicine, Yamagata University Hospital, 2-2-2 Iida-nishi, Yamagata, 990-9585, Japan.
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29
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Reynolds RA, Amin SN, Jonathan SV, Tang AR, Lan M, Wang C, Bastarache JA, Ware LB, Thompson RC. Hyperoxemia and Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2020; 35:30-38. [PMID: 33150573 DOI: 10.1007/s12028-020-01136-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/15/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cerebral vasospasm is a major contributor to disability and mortality after aneurysmal subarachnoid hemorrhage. Oxidation of cell-free hemoglobin plays an integral role in neuroinflammation and is a suggested source of tissue injury after aneurysm rupture. This study sought to determine whether patients with subarachnoid hemorrhage and cerebral vasospasm were more likely to have been exposed to early hyperoxemia than those without vasospasm. METHODS This single-center retrospective cohort study included adult patients presenting with aneurysmal subarachnoid hemorrhage to Vanderbilt University Medical Center between January 2007 and December 2017. Patients with an ICD-9/10 diagnosis of aneurysmal subarachnoid hemorrhage were initially identified (N = 441) and subsequently excluded if they did not have intracranial imaging, arterial PaO2 values or died within 96 h post-rupture (N = 96). The final cohort was 345 subjects. The degree of hyperoxemia was defined by the highest PaO2 measured within 72 h after aneurysmal rupture. The primary outcome was development of cerebral vasospasm, which included asymptomatic vasospasm and delayed cerebral ischemia (DCI). Secondary outcomes were mortality and modified Rankin Scale. RESULTS Three hundred and forty five patients met inclusion criteria; 218 patients (63%) developed vasospasm. Of those that developed vasospasm, 85 were diagnosed with delayed cerebral ischemia (DCI, 39%). The average patient age of the cohort was 55 ± 13 years, and 68% were female. Ninety percent presented with Fisher grade 3 or 4 hemorrhage (N = 310), while 42% presented as Hunt-Hess grade 4 or 5 (N = 146). In univariable analysis, patients exposed to higher levels of PaO2 by quintile of exposure had a higher mortality rate and were more likely to develop vasospasm in a dose-dependent fashion (P = 0.015 and P = 0.019, respectively). There were no statistically significant predictors that differentiated asymptomatic vasospasm from DCI and no significant difference in maximum PaO2 between these two groups. In multivariable analysis, early hyperoxemia was independently associated with vasospasm (OR = 1.15 per 50 mmHg increase in PaO2 [1.03, 1.28]; P = 0.013), but not mortality (OR = 1.10 [0.97, 1.25]; P = 0.147) following subarachnoid hemorrhage. CONCLUSIONS Hyperoxemia within 72 h post-aneurysmal rupture is an independent predictor of cerebral vasospasm, but not mortality in subarachnoid hemorrhage. Hyperoxemia is a variable that can be readily controlled by adjusting the delivered FiO2 and may represent a modifiable risk factor for vasospasm.
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Affiliation(s)
- Rebecca A Reynolds
- Department of Neurological Surgery, Vanderbilt University Medical Center, 1161 21st Avenue South, T4224 Medical Center North, Nashville, TN, 37232-2380, USA.
| | - Shaunak N Amin
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | - Alan R Tang
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Matthews Lan
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Chunxue Wang
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Julie A Bastarache
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, and Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, and Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Reid C Thompson
- Department of Neurological Surgery, Vanderbilt University Medical Center, 1161 21st Avenue South, T4224 Medical Center North, Nashville, TN, 37232-2380, USA
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Neifert SN, Chapman EK, Martini ML, Shuman WH, Schupper AJ, Oermann EK, Mocco J, Macdonald RL. Aneurysmal Subarachnoid Hemorrhage: the Last Decade. Transl Stroke Res 2020; 12:428-446. [PMID: 33078345 DOI: 10.1007/s12975-020-00867-0] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 12/12/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) affects six to nine people per 100,000 per year, has a 35% mortality, and leaves many with lasting disabilities, often related to cognitive dysfunction. Clinical decision rules and more sensitive computed tomography (CT) have made the diagnosis of SAH easier, but physicians must maintain a high index of suspicion. The management of these patients is based on a limited number of randomized clinical trials (RCTs). Early repair of the ruptured aneurysm by endovascular coiling or neurosurgical clipping is essential, and coiling is superior to clipping in cases amenable to both treatments. Aneurysm repair prevents rebleeding, leaving the most important prognostic factors for outcome early brain injury from the hemorrhage, which is reflected in the neurologic condition of the patient, and delayed cerebral ischemia (DCI). Observational studies suggest outcomes are better when patients are managed in specialized neurologic intensive care units with inter- or multidisciplinary clinical groups. Medical management aims to minimize early brain injury, cerebral edema, hydrocephalus, increased intracranial pressure (ICP), and medical complications. Management then focuses on preventing, detecting, and treating DCI. Nimodipine is the only pharmacologic treatment that is approved for SAH in most countries, as no other intervention has demonstrated efficacy. In fact, much of SAH management is derived from studies in other patient populations. Therefore, further study of complications, including DCI and other medical complications, is needed to optimize outcomes for this fragile patient population.
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Affiliation(s)
- Sean N Neifert
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - Emily K Chapman
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - Michael L Martini
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - William H Shuman
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | | | - Eric K Oermann
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - R Loch Macdonald
- University Neurosciences Institutes, University of California San Francisco, Fresno Campus, Fresno, CA, 93701-2302, USA.
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Early Hyperoxia in The Intensive Care Unit is Significantly Associated With Unfavorable Neurological Outcomes in Patients With Mild-to-Moderate Aneurysmal Subarachnoid Hemorrhage. Shock 2020; 51:593-598. [PMID: 30067563 DOI: 10.1097/shk.0000000000001221] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Although oxygen administration is fundamental in the management of aneurysmal subarachnoid hemorrhage (SAH) patients in the acute stage, hyperoxia has harmful effects. The effects of hyperoxia on neurological outcomes in SAH patients are unclear. We aimed to examine the association of hyperoxia during the first 24 h in the intensive care unit (ICU) with unfavorable neurological outcomes in SAH patients. METHODS We retrospectively selected consecutive adult patients admitted to ICU for SAH between January 2009 and April 2018. We defined normoxia during the first 24 h in ICU as PaO2 of 60 mm Hg to 120 mm Hg, mild hyperoxia as PaO2 of 121 mm Hg to 200 mm Hg, moderate hyperoxia as PaO2 of 201 mm Hg to 300 mm Hg, and severe hyperoxia as PaO2 of >300 mm Hg. Univariate and multivariate analyses were performed to examine the association between hyperoxia during the first 24 h in ICU and unfavorable neurological outcomes (i.e., modified Rankin scale score of 3-6 at hospital discharge). RESULTS Among 196 SAH patients, 90 had unfavorable neurological outcomes. Hyperoxia was observed in 93.4% of patients. No significant association was observed between unfavorable neurological outcomes and hyperoxia in overall patients. However, we found that early hyperoxia in ICU was significantly associated with unfavorable neurological outcomes in SAH patients with Hunt and Kosnik (H&K) grades I to III (Relative risk, 1.84; 95% confidence interval, 1.10-2.94; P = 0.02). CONCLUSIONS Early hyperoxia was not associated with unfavorable neurological outcomes in overall SAH patients, but it was associated with unfavorable neurological outcomes in those with H&K grades I to III.
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Okazaki T, Yokoyama S, Kawakita K, Kuroda Y. Letter to the Editor. Is time-weighted PaO₂ during the hyperacute phase of aneurysmal subarachnoid hemorrhage really helpful in usual care settings? J Neurosurg 2020; 134:325-326. [PMID: 32276254 DOI: 10.3171/2020.1.jns20177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Liu Q, Zhu C, Lan C, Chen R. High-flow nasal cannula versus conventional oxygen therapy in patients with dyspnea and hypoxemia before hospitalization. Expert Rev Respir Med 2020; 14:425-433. [PMID: 31985296 DOI: 10.1080/17476348.2020.1722642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: Patients with dyspnea and hypoxemia are common in emergency departments. However, it is unknown whether high-flow nasal cannula (HFNC) reduces the risk of requiring more advanced ventilation support and whether HFNC relieves dyspnea better than conventional oxygen therapy (COT).Areas covered: We searched the PubMed, Cochrane Library, Ovid, and Embase databases from inception to 1 September 2019 to identify relevant-randomized controlled trials comparing the effect of HFNC with COT in emergency departments regarding the severity of dyspnea, hospitalization rate, intubation rate, and hospital mortality. We identified four studies. HFNC was associated with a lower rate of requiring more advanced ventilation. HFNC reduced the rate of dyspnea, lowered the dyspnea scale score, and decreased patients' respiratory rate significantly. However, there was insufficient evidence to show a significant effect on HFNC regarding patients' oxygenation and hospital mortality.Expert opinion: For patients with dyspnea and hypoxemia before hospitalization, the short-term effect of HFNC was undeniable. HFNC reduced the risk of requiring more advanced ventilation and relived dyspnea better than COT. HFNC might be considered as a first-line therapy even before making a clear diagnosis for dyspnea.More studies are needed to explore the effect of HFNC on oxygenation and patients' prognosis.
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Affiliation(s)
- Qi Liu
- Emergency Intensive Care Ward, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, PR China
| | - Changju Zhu
- Emergency Intensive Care Ward, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, PR China
| | - Chao Lan
- Emergency Intensive Care Ward, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, PR China
| | - Rongchang Chen
- Shenzhen People's Hospital, Shenzhen Institute of Respiratory Diseases, China.,State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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Impact of Hyperoxia and Hypocapnia on Neurological Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study. Crit Care Res Pract 2019; 2019:7584573. [PMID: 31885915 PMCID: PMC6925754 DOI: 10.1155/2019/7584573] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/04/2019] [Accepted: 11/11/2019] [Indexed: 01/13/2023] Open
Abstract
In recent decades, there is increasing evidence suggesting that hyperoxia and hypocapnia are associated with poor outcomes in critically ill patients with cardiac arrest or traumatic brain injury. Yet, the impact of hyperoxia and hypocapnia on neurological outcome in patients with subarachnoid hemorrhage (SAH) has not been well studied. In the present study, we evaluated the impact of hyperoxia and hypocapnia on neurological outcomes in patients with aneurysmal SAH (aSAH). Patients with aSAH who were admitted to the intensive care unit (ICU) of a tertiary hospital in Hong Kong between January 2011 and December 2016 were retrospectively recruited. Patients' demographics, comorbidities, radiological findings, clinical grades of SAH, PO2, and PCO2 within 24 hours of ICU admission, and Glasgow Outcome Scale (GOS) at 3 months after admission were recorded. Patients with a GOS score of 3 or less were considered having poor neurological outcomes. Among the 244 patients with aSAH, 122 of them (50%) had poor neurological outcomes at 3 months. Early hyperoxia (PO2 > 200 mmHg) and hypercapnia (PCO2 > 45 mmHg) were more common among patients with poor neurological outcomes. Logistic regression analysis indicated that hyperoxia independently predicted poor neurological outcomes (OR 3.788, 95% CI 1.131-12.690, P=0.031). Classification tree analysis revealed that hypocapnia was associated with poor neurological outcomes in patients who were less critically ill (APACHE < 50) and without concomitant intracranial hemorrhage (ICH) or intraventricular hemorrhage (IVH) (adjusted P=0.006, χ 2 = 7.452). These findings suggested that hyperoxia and hypocapnia may be associated with poor neurological outcomes in patients with aSAH.
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Robba C, Bonatti G, Battaglini D, Rocco PRM, Pelosi P. Mechanical ventilation in patients with acute ischaemic stroke: from pathophysiology to clinical practice. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:388. [PMID: 31791375 PMCID: PMC6889568 DOI: 10.1186/s13054-019-2662-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 10/25/2019] [Indexed: 12/17/2022]
Abstract
Most patients with ischaemic stroke are managed on the ward or in specialty stroke units, but a significant number requires higher-acuity care and, consequently, admission to the intensive care unit. Mechanical ventilation is frequently performed in these patients due to swallowing dysfunction and airway or respiratory system compromise. Experimental studies have focused on stroke-induced immunosuppression and brain-lung crosstalk, leading to increased pulmonary damage and inflammation, as well as reduced alveolar macrophage phagocytic capability, which may increase the risk of infection. Pulmonary complications, such as respiratory failure, pneumonia, pleural effusions, acute respiratory distress syndrome, lung oedema, and pulmonary embolism from venous thromboembolism, are common and found to be among the major causes of death in this group of patients. Furthermore, over the past two decades, tracheostomy use has increased among stroke patients, who can have unique indications for this procedure—depending on the location and type of stroke—when compared to the general population. However, the optimal mechanical ventilator strategy remains unclear in this population. Although a high tidal volume (VT) strategy has been used for many years, the latest evidence suggests that a protective ventilatory strategy (VT = 6–8 mL/kg predicted body weight, positive end-expiratory pressure and rescue recruitment manoeuvres) may also have a role in brain-damaged patients, including those with stroke. The aim of this narrative review is to explore the pathophysiology of brain-lung interactions after acute ischaemic stroke and the management of mechanical ventilation in these patients.
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Affiliation(s)
- Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.
| | - Giulia Bonatti
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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Fukuda S, Koga Y, Fujita M, Suehiro E, Kaneda K, Oda Y, Ishihara H, Suzuki M, Tsuruta R. Hyperoxemia during the hyperacute phase of aneurysmal subarachnoid hemorrhage is associated with delayed cerebral ischemia and poor outcome: a retrospective observational study. J Neurosurg 2019; 134:25-32. [PMID: 31731268 DOI: 10.3171/2019.9.jns19781] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 09/11/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The harmful effects of hyperoxemia have been reported in critically ill patients with various disorders, including those with brain injuries. However, the effect of hyperoxemia on aneurysmal subarachnoid hemorrhage (aSAH) patients is unclear. In this study the authors aimed to determine whether hyperoxemia during the hyperacute or acute phase in patients with aSAH is associated with delayed cerebral ischemia (DCI) and poor neurological outcome. METHODS In this single-center retrospective study, data from patients with aSAH treated between January 2011 and June 2017 were reviewed. The patients were classified into groups according to whether they experienced DCI (DCI group and non-DCI group) and whether they had a poor outcome at discharge (poor outcome group and favorable outcome group). The background characteristics and time-weighted average (TWA) PaO2 during the first 24 hours after arrival at the treatment facility (TWA24h-PaO2) and between the first 24 hours after arrival and day 6 (TWA6d-PaO2), the hyperacute and acute phases, respectively, were compared between the groups. Factors related to DCI and poor outcome were evaluated with logistic regression analyses. RESULTS Of 197 patients with aSAH, 42 patients experienced DCI and 82 patients had a poor outcome at discharge. TWA24h-PaO2 was significantly higher in the DCI group than in the non-DCI group (186 [141-213] vs 161 [138-192] mm Hg, p = 0.029) and in the poor outcome group than in the favorable outcome group (176 [154-205] vs 156 [136-188] mm Hg, p = 0.004). TWA6d-PaO2 did not differ significantly between the groups. Logistic regression analyses revealed that higher TWA24h-PaO2 was an independent risk factor for DCI (OR 1.09, 95% CI 1.01-1.17, p = 0.037) and poor outcome (OR 1.17, 95% CI 1.06-1.29, p = 0.002). CONCLUSIONS Hyperoxemia during the first 24 hours was associated with DCI and a poor outcome in patients with aSAH. Excessive oxygen therapy might have an adverse effect in the hyperacute phase of aSAH.
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Affiliation(s)
- Shinya Fukuda
- 1Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, Yamaguchi; and
| | - Yasutaka Koga
- 1Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, Yamaguchi; and
| | | | - Eiichi Suehiro
- 1Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, Yamaguchi; and
- 3Department of Neurosurgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Kotaro Kaneda
- 1Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, Yamaguchi; and
| | | | - Hideyuki Ishihara
- 3Department of Neurosurgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Michiyasu Suzuki
- 3Department of Neurosurgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Ryosuke Tsuruta
- 1Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, Yamaguchi; and
- 2Acute and General Medicine and
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Roffe C, Nevatte T, Bishop J, Sim J, Penaloza C, Jowett S, Ives N, Gray R, Ferdinand P, Muddegowda G. Routine low-dose continuous or nocturnal oxygen for people with acute stroke: three-arm Stroke Oxygen Supplementation RCT. Health Technol Assess 2019; 22:1-88. [PMID: 29595449 DOI: 10.3310/hta22140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Stroke is a major cause of death and disability worldwide. Hypoxia is common after stroke and is associated with worse outcomes. Oxygen supplementation could prevent hypoxia and secondary brain damage. OBJECTIVES (1) To assess whether or not routine low-dose oxygen supplementation in patients with acute stroke improves outcome compared with no oxygen; and (2) to assess whether or not oxygen given at night only, when oxygen saturation is most likely to be low, is more effective than continuous supplementation. DESIGN Multicentre, prospective, randomised, open, blinded-end point trial. SETTING Secondary care hospitals with acute stroke wards. PARTICIPANTS Adult stroke patients within 24 hours of hospital admission and 48 hours of stroke onset, without definite indications for or contraindications to oxygen or a life-threatening condition other than stroke. INTERVENTIONS Allocated by web-based minimised randomisation to: (1) continuous oxygen: oxygen via nasal cannula continuously (day and night) for 72 hours after randomisation at a flow rate of 3 l/minute if baseline oxygen saturation was ≤ 93% or 2 l/minute if > 93%; (2) nocturnal oxygen: oxygen via nasal cannula overnight (21:00-07:00) for three consecutive nights. The flow rate was the same as the continuous oxygen group; and (3) control: no routine oxygen supplementation unless required for reasons other than stroke. MAIN OUTCOME MEASURES Primary outcome: disability assessed by the modified Rankin Scale (mRS) at 3 months by postal questionnaire (participant aware, assessor blinded). Secondary outcomes at 7 days: neurological improvement, National Institutes of Health Stroke Scale (NIHSS), mortality, and the highest and lowest oxygen saturations within the first 72 hours. Secondary outcomes at 3, 6, and 12 months: mortality, independence, current living arrangements, Barthel Index, quality of life (European Quality of Life-5 Dimensions, three levels) and Nottingham Extended Activities of Daily Living scale by postal questionnaire. RESULTS In total, 8003 patients were recruited between 24 April 2008 and 17 June 2013 from 136 hospitals in the UK [continuous, n = 2668; nocturnal, n = 2667; control, n = 2668; mean age 72 years (standard deviation 13 years); 4398 (55%) males]. All prognostic factors and baseline characteristics were well matched across the groups. Eighty-two per cent had ischaemic strokes. At baseline the median Glasgow Coma Scale score was 15 (interquartile range 15-15) and the mean and median NIHSS scores were 7 and 5 (range 0-34), respectively. The mean oxygen saturation at randomisation was 96.6% in the continuous and nocturnal oxygen groups and 96.7% in the control group. Primary outcome: oxygen supplementation did not reduce disability in either the continuous or the nocturnal oxygen groups. The unadjusted odds ratio for a better outcome (lower mRS) was 0.97 [95% confidence interval (CI) 0.89 to 1.05; p = 0.5] for the combined oxygen groups (both continuous and nocturnal together) (n = 5152) versus the control (n = 2567) and 1.03 (95% CI 0.93 to 1.13; p = 0.6) for continuous versus nocturnal oxygen. Secondary outcomes: oxygen supplementation significantly increased oxygen saturation, but did not affect any of the other secondary outcomes. LIMITATIONS Severely hypoxic patients were not included. CONCLUSIONS Routine low-dose oxygen supplementation in stroke patients who are not severely hypoxic is safe, but does not improve outcome after stroke. FUTURE WORK To investigate the causes of hypoxia and develop methods of prevention. TRIAL REGISTRATION Current Controlled Trials ISRCTN52416964 and European Union Drug Regulating Authorities Clinical Trials (EudraCT) number 2006-003479-11. FUNDING DETAILS This project was funded by the National Institute for Health Research (NIHR) Research for Patient Benefit and Health Technology Assessment programmes and will be published in full in Health Technology Assessment; Vol. 22, No. 14. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Christine Roffe
- Institute for Applied Clinical Sciences, Keele University, Keele, UK
| | | | - Jon Bishop
- University of Birmingham, Birmingham, UK
| | | | | | - Susan Jowett
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | | | | | | | - Girish Muddegowda
- Neurosciences Department, Royal Stoke University Hospital, Stoke-on-Trent, UK
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Kongebro EK, Jorgensen LN, Siersma VD, Meyhoff C. Association between perioperative hyperoxia and cerebrovascular complications after laparotomy-A post-hoc follow-up study. Acta Anaesthesiol Scand 2019; 63:164-170. [PMID: 30066392 DOI: 10.1111/aas.13235] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 06/21/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Perioperative hyperoxia has been linked to increased long-term mortality. Vasoconstrictive and cellular side effects to hyperoxia have been suggested to increase the risk of coronary and cerebral ischemia. The aim of this post-hoc analysis of a large randomized trial was to compare the effects of 80% vs 30% perioperative oxygen on the long-term risk of stroke or transient cerebral ischemia (TCI) in patients undergoing abdominal surgery. METHODS A total of 1386 patients were randomized to 80% or 30% perioperative oxygen during acute or elective open abdominal surgery. Median follow-up was 3.9 years. Primary outcome was a composite of the long-term occurrence of stroke or TCI. Secondary outcomes included long-term mortality without stroke or TCI, and incidences of neurological admission, psychiatric admission, and dementia. Outcomes were analyzed in Cox regression models. RESULTS Stroke or TCI occurred in 20 (3.0%) patients given 80% oxygen vs 22 (3.2%) patients given 30% oxygen with an adjusted hazard ratio (HR) of 0.96 [95% CI 0.52-1.76]. Composite secondary outcome of death, stroke, or TCI had a HR of 1.21 [95% CI 1.00-1.47] for 80% compared to 30% oxygen. HRs for secondary outcomes were HR 1.14 [95% CI 0.79-1.64] for neurological admission, 1.34 [95% CI 0.95-1.88] for psychiatric admission and 0.54 [95% CI 0.16-1.80] for dementia. CONCLUSION Stroke or TCI did not seem related to perioperative inspiratory oxygen fraction. Due to few events, this study cannot exclude that perioperative hyperoxia increases risk of mortality, stroke, or TCI after abdominal surgery.
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Affiliation(s)
- Emilie Katrine Kongebro
- Department of Anaesthesia and Intensive Care; Bispebjerg and Frederiksberg Hospital; University of Copenhagen; Copenhagen Denmark
| | - Lars N. Jorgensen
- Digestive Disease Center; Bispebjerg and Frederiksberg Hospital; University of Copenhagen; Copenhagen Denmark
| | - Volkert D. Siersma
- The Research Unit for General Practice and Section of General Practice; Department of Public Health; University of Copenhagen; Copenhagen Denmark
| | - Christian Sahlholt Meyhoff
- Department of Anaesthesia and Intensive Care; Bispebjerg and Frederiksberg Hospital; University of Copenhagen; Copenhagen Denmark
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Jeong JH, Kim DH, Kim TY, Kang C, Lee SH, Lee SB, Kim SC, Park YJ. Harmful effects of early hyperoxaemia in patients admitted to general wards: an observational cohort study in South Korea. BMJ Open 2018; 8:e021758. [PMID: 30366913 PMCID: PMC6224716 DOI: 10.1136/bmjopen-2018-021758] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES We evaluated the association between hyperoxaemia induced by a non-invasive oxygen supply for 3 days after emergency department (ED) arrival and the clinical outcomes at day 5 after ED arrival. DESIGN Observational cohort study. SETTING AND PATIENTS Consecutive ED patients ≥16 years of age with available arterial blood gas analysis results who were admitted to our hospital were enrolled from January 2010 to December 2016. INTERVENTIONS The highest (PaO2MAX), average (PaO2AVG) and median (PaO2MED) PaO2 (arterial oxygen pressure) values within 72 hours and the area under the curve divided by the time elapsed between ED admittance and the last PaO2 result (AUC72) were used to assess hyperoxaemia. The AUC72 values were calculated using the trapezoid rule. OUTCOMES The primary outcome was the 90-day in-hospital mortality rate. The secondary outcomes were intensive care unit (ICU) transfer and respiratory failure at day 5 after ED arrival, as well as new-onset cardiovascular, coagulation, hepatic and renal dysfunction at day 5 after ED arrival. RESULTS Among the 10 141 patients, the mortality rate was 5.8%. The adjusted ORs of in-hospital mortality for PaO2MAX, PaO2AVG, PaO2MED and AUC72 were 0.79 (95% CI 0.61 to 1.02; p=0.0715), 0.92 (95% CI 0.69 to 1.24; p=0.5863), 0.82 (95% CI 0.61 to 1.11; p=0.2005) and 1.53 (95% CI 1.25 to 1.88; p<0.0001). All of the hyperoxaemia variables showed significant positive correlations with ICU transfer at day 5 after ED arrival (p<0.05). AUC72 was positively correlated with respiratory failure, as well as cardiovascular, hepatic and renal dysfunction (p<0.05). PaO2MAX was positively correlated with cardiovascular dysfunction. PaO2MAX and AUC72 were negatively correlated with coagulation dysfunction (p<0.05). CONCLUSIONS Hyperoxaemia during the first 3 days in patients outside the ICU is associated with in-hospital mortality and ICU transfer at day 5 after arrival at the ED.
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Affiliation(s)
- Jin Hee Jeong
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Republic of Korea
- Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju-si, Republic of Korea
| | - Dong Hoon Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Republic of Korea
- Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju-si, Republic of Korea
| | - Tae Yun Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Republic of Korea
| | - Changwoo Kang
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Republic of Korea
- Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju-si, Republic of Korea
| | - Soo Hoon Lee
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Republic of Korea
| | - Sang Bong Lee
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Republic of Korea
| | - Seong Chun Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Yong Joo Park
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
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Grensemann J, Fuhrmann V, Kluge S. Oxygen Treatment in Intensive Care and Emergency Medicine. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:455-462. [PMID: 30064624 PMCID: PMC6111205 DOI: 10.3238/arztebl.2018.0455] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 11/02/2017] [Accepted: 03/26/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Oxygen treatment is often life-saving, but multiple studies in recent years have yielded evidence that the indiscriminate administration of oxygen to patients in the intensive care unit and emergency room can cause hyperoxia and thereby elevate mortality. METHODS This review is based on prospective, randomized trials concerning the optimum use of oxygen in adult medicine, which were retrieved by a selective search in PubMed, as well as on pertinent retrospective studies and guideline recommendations. RESULTS 13 prospective, randomized trials involving a total of 17 213 patients were analyzed. In patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) and in ventilated intensive-care patients, normoxia was associated with a lower mortality than hyperoxia (2% vs. 9%). In patients with myocardial infarction, restrictive oxygen administration was associated with a smaller infarct size on cardiac MRI at 6 months compared to oxygen administration at 8 L/min (13.1 g vs. 20.3 g). For patients with stroke, the currently available data do not reveal any benefit or harm from oxygen administration. None of the trials showed any benefit from the administration of oxygen to non-hypoxemic patients; in fact, this was generally associated with increased morbidity or mortality. CONCLUSION Hypoxemia should certainly be avoided, but the fact that the liberal administration of oxygen to patients in intensive care units and emergency rooms tends to increase morbidity and mortality implies the advisability of a conservative, normoxic oxygenation strategy.
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Affiliation(s)
- Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Zafar SF, Postma EN, Biswal S, Fleuren L, Boyle EJ, Bechek S, O'Connor K, Shenoy A, Jonnalagadda D, Kim J, Shafi MS, Patel AB, Rosenthal ES, Westover MB. Electronic Health Data Predict Outcomes After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2018; 28:184-193. [PMID: 28983801 PMCID: PMC5886829 DOI: 10.1007/s12028-017-0466-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUD Using electronic health data, we sought to identify clinical and physiological parameters that in combination predict neurologic outcomes after aneurysmal subarachnoid hemorrhage (aSAH). METHODS We conducted a single-center retrospective cohort study of patients admitted with aSAH between 2011 and 2016. A set of 473 predictor variables was evaluated. Our outcome measure was discharge Glasgow Outcome Scale (GOS). For laboratory and physiological data, we computed the minimum, maximum, median, and variance for the first three admission days. We created a penalized logistic regression model to determine predictors of outcome and a multivariate multilevel prediction model to predict poor (GOS 1-2), intermediate (GOS 3), or good (GOS 4-5) outcomes. RESULTS One hundred and fifty-three patients met inclusion criteria; most were discharged with a GOS of 3. Multivariate analysis predictors of mortality (AUC 0.9198) included APACHE II score, Glasgow Come Scale (GCS), white blood cell (WBC) count, mean arterial pressure, variance of serum glucose, intracranial pressure (ICP), and serum sodium. Predictors of death/dependence versus independence (GOS 4-5)(AUC 0.9456) were levetiracetam, mechanical ventilation, WBC count, heart rate, ICP variance, GCS, APACHE II, and epileptiform discharges. The multiclass prediction model selected GCS, admission APACHE II, periodic discharges, lacosamide, and rebleeding as significant predictors; model performance exceeded 80% accuracy in predicting poor or good outcome and exceeded 70% accuracy for predicting intermediate outcome. CONCLUSIONS Variance in early physiologic data can impact patient outcomes and may serve as targets for early goal-directed therapy. Electronically retrievable features such as ICP, glucose levels, and electroencephalography patterns should be considered in disease severity and risk stratification scores.
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Affiliation(s)
- Sahar F Zafar
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Eva N Postma
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Siddharth Biswal
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Lucas Fleuren
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Emily J Boyle
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Sophia Bechek
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Kathryn O'Connor
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Apeksha Shenoy
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Durga Jonnalagadda
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Jennifer Kim
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Mouhsin S Shafi
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Eric S Rosenthal
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - M Brandon Westover
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
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Wepler M, Demiselle J, Radermacher P, Asfar P, Calzia E. Before the ICU: does emergency room hyperoxia affect outcome? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018. [PMID: 29519235 PMCID: PMC5844124 DOI: 10.1186/s13054-018-1980-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Martin Wepler
- Klinik für Anästhesiologie, Universitätsklinikum Ulm, 89081, Ulm, Germany.,Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Helmholtzstrasse 8/1, 89081, Ulm, Germany
| | - Julien Demiselle
- Médecine Intensive-Réanimation et Médecine Hyperbare, Centre Hospitalier Universitaire Angers, 49933, Angers, France
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Helmholtzstrasse 8/1, 89081, Ulm, Germany
| | - Pierre Asfar
- Médecine Intensive-Réanimation et Médecine Hyperbare, Centre Hospitalier Universitaire Angers, 49933, Angers, France
| | - Enrico Calzia
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Helmholtzstrasse 8/1, 89081, Ulm, Germany.
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Taccone FS, Crippa IA, Vincent JL. Normobaric hyperoxia after stroke: a word of caution. Expert Rev Neurother 2017; 18:91-93. [DOI: 10.1080/14737175.2018.1414600] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Ilaria Alice Crippa
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Xu B, Ji Q, Zhang Y, Shen L, Cao M, Cai K. Postoperative blood pressure variability exerts an influence on clinical outcome after coil embolization of ruptured intracranial aneurysms. Neurol Res 2017; 39:813-818. [PMID: 28675964 DOI: 10.1080/01616412.2017.1348653] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Bin Xu
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
| | - Qiuhong Ji
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
| | - Yunfeng Zhang
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
| | - Lihua Shen
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
| | - Maohong Cao
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
| | - Kefu Cai
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
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Vidal-Jorge M, Sánchez-Guerrero A, Mur-Bonet G, Castro L, Rădoi A, Riveiro M, Fernández-Prado N, Baena J, Poca MA, Sahuquillo J. Does Normobaric Hyperoxia Cause Oxidative Stress in the Injured Brain? A Microdialysis Study Using 8-Iso-Prostaglandin F2α as a Biomarker. J Neurotrauma 2017; 34:2731-2742. [PMID: 28323516 DOI: 10.1089/neu.2017.4992] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Significant controversy exists regarding the potential clinical benefit of normobaric hyperoxia (NBO) in patients with traumatic brain injury (TBI). This study consisted of two aims: 1) to assess whether NBO improves brain oxygenation and metabolism and 2) to determine whether this therapy may increase the risk of oxidative stress (OxS), using 8-iso-Prostaglandin F2α (PGF2α) as a biomarker. Thirty-one patients with a median admission Glasgow Coma Scale score of 4 (min: 3, max: 12) were monitored with cerebral microdialysis and brain tissue oxygen sensors and treated with fraction of inspired oxygen (FiO2) of 1.0 for 4 h. Patients were divided into two groups according to the area monitored by the probes: normal injured brain and traumatic penumbra/traumatic core. NBO maintained for 4 h did not induce OxS in patients without preOxS at baseline, except in one case. However, for patients in whom OxS was detected at baseline, NBO induced a significant increase in 8-iso-PGF2α. The results of our study showed that NBO did not change energy metabolism in the whole group of patients. In the five patients with brain lactate concentration ([Lac]brain) > 3.5 mmol/L at baseline, NBO induced a marked reduction in both [Lac]brain and lactate-to-pyruvate ratio. Although these differences were not statistically significant, together with the results of our previous study, they suggest that TBI patients would benefit from receiving NBO when they show indications of disturbed brain metabolism. These findings, in combination with increasing evidence that TBI metabolic crises are common without brain ischemia, open new possibilities for the use of this accessible therapeutic strategy in TBI patients.
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Affiliation(s)
- Marian Vidal-Jorge
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Angela Sánchez-Guerrero
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Gemma Mur-Bonet
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Lidia Castro
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Andreea Rădoi
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Marilyn Riveiro
- 2 Neurotraumatology Intensive Care Unit, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Natalia Fernández-Prado
- 2 Neurotraumatology Intensive Care Unit, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jacinto Baena
- 2 Neurotraumatology Intensive Care Unit, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria-Antonia Poca
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain .,3 Department of Neurosurgery, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Sahuquillo
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain .,3 Department of Neurosurgery, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
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Abstract
Subarachnoid hemorrhage (SAH) affects 30,000 people in the Unites States alone each year. Delayed cerebral ischemia occurs days after subarachnoid hemorrhage and represents a potentially treatable cause of morbidity for approximately one-third of those who survive the initial hemorrhage. While vasospasm has been traditionally linked to the development of cerebral ischemia several days after subarachnoid hemorrhage, emerging evidence reveals that delayed cerebral ischemia is part of a much more complicated post-subarachnoid hemorrhage syndrome. The development of delayed cerebral ischemia involves early arteriolar vasospasm with microthrombosis, perfusion mismatch and neurovascular uncoupling, spreading depolarizations, and inflammatory responses that begin at the time of the hemorrhage and evolve over time, culminating in cortical infarction. Large-vessel vasospasm is likely a late contributor to ongoing injury, and effective treatment for delayed cerebral ischemia will require improved detection of critical early pathophysiologic changes as well as therapeutic options that target multiple related pathways.
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Harmful Effects of Hyperoxia in Postcardiac Arrest, Sepsis, Traumatic Brain Injury, or Stroke: The Importance of Individualized Oxygen Therapy in Critically Ill Patients. Can Respir J 2017; 2017:2834956. [PMID: 28246487 PMCID: PMC5299175 DOI: 10.1155/2017/2834956] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 12/27/2016] [Indexed: 11/29/2022] Open
Abstract
The beneficial effects of oxygen are widely known, but the potentially harmful effects of high oxygenation concentrations in blood and tissues have been less widely discussed. Providing supplementary oxygen can increase oxygen delivery in hypoxaemic patients, thus supporting cell function and metabolism and limiting organ dysfunction, but, in patients who are not hypoxaemic, supplemental oxygen will increase oxygen concentrations into nonphysiological hyperoxaemic ranges and may be associated with harmful effects. Here, we discuss the potentially harmful effects of hyperoxaemia in various groups of critically ill patients, including postcardiac arrest, traumatic brain injury or stroke, and sepsis. In all these groups, there is evidence that hyperoxia can be harmful and that oxygen prescription should be individualized according to repeated assessment of ongoing oxygen requirements.
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Lång M, Raj R, Skrifvars MB, Koivisto T, Lehto H, Kivisaari R, von Und Zu Fraunberg M, Reinikainen M, Bendel S. Early Moderate Hyperoxemia Does Not Predict Outcome After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2016; 78:540-5. [PMID: 26562823 DOI: 10.1227/neu.0000000000001111] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Targeting hyperoxemia is common practice in neurocritical care settings, but the safety of hyperoxemia has been questioned. OBJECTIVE To investigate the independent effect of hyperoxemia on outcome in patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS We included 432 patients with aneurysmal SAH on mechanical ventilation for at least 24 hours after intensive care unit (ICU) admission. Arterial blood gas levels were calculated as time-weighted averages (TWAs) of all blood gas measurements during the first 24 hours in the ICU. Patients were categorized into 3 TWA-PaO2 bands (low, <97.5 mm Hg; intermediate, 97.5-150 mm Hg; high, ≥150 mm Hg). Outcome measures were unfavorable outcome at 3 months (Glasgow Outcome Scale score 1-3) and mortality. Multivariate logistic regression analysis was used to assess the independent effect of oxygen on outcome. RESULTS Overall, 28% of patients died, and a total of 53% had an unfavorable outcome at 3 months. Patients with an unfavorable outcome had significantly higher TWA-PaO2 levels compared with patients with a favorable outcome (137 mm Hg vs 118 mm Hg, P < .001). Multivariate analysis demonstrated no significant association between TWA-PaO2 bands and unfavorable outcome (with intermediate PaO2 as a reference, odds ratio [OR] for low PaO2 1.05, 95% confidence interval [CI]: 0.52-2.12, P = .89; OR for high PaO2: 1.09, 95% CI: 0.61-1.97, P = .77) or mortality (with intermediate PaO2 as reference, the OR for low PaO2 was 0.67 (95% CI: 0.30-1.46, P = .31), and the OR for high PaO2 was 0.73 (95% CI: 0.38-1.40, P = .34). CONCLUSION Early moderate hyperoxemia may not increase or decrease the risk of a poor outcome in mechanically ventilated aneurysmal SAH patients.
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Affiliation(s)
- Maarit Lång
- *Department of Intensive Care Medicine, Kuopio University Hospital, Kuopio, Finland; ‡Department of Neurosurgery, University of Helsinki, Helsinki University Central Hospital, Helsinki, Finland; §Division of Intensive Care, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland; ¶Department of Neurosurgery, Kuopio University Hospital, Kuopio, Finland; ‖Department of Intensive Care Medicine, North Karelia Central Hospital, Joensuu, Finland
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Borsellino B, Schultz MJ, Gama de Abreu M, Robba C, Bilotta F. Mechanical ventilation in neurocritical care patients: a systematic literature review. Expert Rev Respir Med 2016; 10:1123-32. [DOI: 10.1080/17476348.2017.1235976] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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